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J
9 9015 00382 604
Lf ox
MEDICO-CHIRURGICAL
TRANSACTIONS.
PUBLISHED BY
THE ROYAL
MEDICAL AND CHIRURGICAL SOCIETY
OF
LONDON.
VOLUME THE THIRTY-SEVENTH.
LONDON :
LONGMAN, BROWN, GREEN, AND LONGMANS,
PATERNOSTER-ROW.
1854
MEDICO-C HIRURGICAL
TRANSACTIONS.
fublishes bz
THE EOYAL
MEDICAL AND CHIRURGICAL SOCIETY
LONDON.
SECOND SERIES.
VOLUME THE NINETEENTH.
LONDON :
LONGMAN, BROWN. GREEN, AND LONGMANS.
PATERNOSTER-ROW.
ADVERTISEMENT.
The Council of the Royal Medical and Chirurgical Society
deems it proper to state, that the Society does not hold
itself in any way responsible for the statements, reasonings^
or opinions set forth in the various papers, which, on grounds
of general merit, are thought worthy of being published in
its Transactions.
CONTENTS.
PAGE
List of Officers and Council . . . . v
List of Referees . . . . vii
List of Presidents of the Society .... viii
List of Fellows of the Society . . . . xi
I. Scrofulous Caries of the Left; Astralagns. Excision — cure, with
formation of a Fresh Joint. By S. F. Statham, Assistant-Surgeon
University College Hospital 1
n. Fatholoffical Bemarks on the kind of Palpebral Tumour usually
called, in England, Tarsal Tumour, by H. Haynes Walton,
Esq., F.E..C.8., Surgeon to the Central London Ophthalmic
called, in England, Tarsal Tumour, by H. Haynes Walton,
Esq., F.E..C.8., Surgeon to the Central London Ophthalmic
Hospital ; Assistant-Surgeon to St. Mary's Hospital . . 7
III. Notice of a Case of Skin Disease, accompanied with partial
Hypertrophy of the Mammary Gland. By James Alderson,
M.I)., F.fe.S., Senior Physician to St. Mary s Hospital; One of
the Vice-Presidents of the Society 13
IV. Case of Mollities Ossium, preceded by Degeneration of the
Muscles. By Thomas K. Chambers, M.D., Physician to St.
Mary's Hospital 19
V. On the Keloid of Alibert, and on True Keloid. By Thos. Addison,
M.D., Physician to Guy's Hospital 27
VI. On the Blood and Effused Fluids of Gout, Bheumatism, and
Bright's Disease. By Alfred B. Garrod, M.D., Professor of
Materia Medica, Therapeutics, and Clinical Medicine, at Uni-
versity College ; and Physician to University College Hospital.
(Second Communication) 49
VII. On Excision of the Knee-Joint. By G. M. Jones, Esq.,
M.R.C.S.E., Surgeon to the Jersey Hospital . . . .61
VIII. On the Radical Cure of Reducible Inguinal Hernia, by a New
57
Operation, with Cases and Remarks. By T. Spencer Wells,
F.R.C.S.
xxxvii.
Xlii CONTENTS.
PAGE
IX. Observations of Morbid Changes in the Mucous Membrane of the
Stomach. By Dr. Hanfield Jones. Communicated by Dr.
Bence Jones 87
X. A Case of Fatal Asphyxia, caused by the detachment of a diseased
Bronchial Gland which was impacted in the Larynx. By
George Edwardes,- of Wolverhampton, Fellow of the Eoyal
College of Sur^ons of England, and of the Eoyal Medical and
Chirur^cal Society of London; late Surgeon to the South
Staffordshire General Hospital 151
XI. Remarks on a peculiar form of Tumour of the Skin, denominated
" Pachydermatocele," illustrated by Cases. By Valentine Mott,
M.D., C.L.D., Emeritus Professor of Surgery in the University
of New York 155
Xn. Case of Distortion of the Spine, with observations on Rotation of
the Yertebrse as a complication of Lateral Curvature. By Thos.
Hodgkin, M.D., L.K.C.P., and Wm. Adams, F.KC.S., Assist-
ant-Sur^on to the Eoycd Orthopaedic Hospital ; Demonstrator
of Morbid Anatomy at St. Thomas*s Hospital .... 167
Xm. On Gout and Blieumatism. The differential Diagnosis, and the
Nature of the so-called Rheumatic Gout. By Alfred Baring
G^arrod^ M.D., Professor of Materia Medica, Therapeutics, and
Clinical Medicine, at University College ; Physician to Univer-
sity College Hospital 181
XrV. Case of Traumatic Aneurism of the Ophthalmic Artery, conse-
quent on Injury of the Head, cured by Ligature of the common
Carotid Artery. By T. B. Curling, F.R.S., Surgeon to the
London Hospital 221
XY. Endish Statistics of Hooping-Cough. By Edward Smith, M.D.,
LL.B., London University, &c.. Honorary Secretary of the
Medical Society of London. Communicated by H. Bence
Jones, M.D 227
Donations to the Library ... 255
Index ............ 261
EOYAL
MEDICAL AND CHIRUMICAL SOCIETY
m
OF LONDON.
PATRON.
THE QUEEN,
OFFICERS AND COUNCIL,
ELECTED MARCH 1, 1854.
JAMES COPLAND, M.D. F.R.S.
VICE-PRESIDENTS.
TBBA8UBEBS.
SECBETABIES.
LIBBABIAN8.
I
{
OTHEB MEMBEBS
OF COUNCIL.
^THOMAS ALFRED BARKER, M.D.
ROBERT BENTLEY TODD, M.D. F.R.S.
THOMAS BELL, F.R.S.
THOMAS WORMALD.
JOSEPH MOORE, M.D.
THOMAS BLIZARD CURLING, F.R.S.
. WILLIAM R. BASH AM, M.D.
i HOLMES COOTE.
r WILLIAM WEGG, M.D.
1 JAMES DIXON,
r GEORGE CHAPLIN CHILD, M.D.
WILLIAM DINGLE CHOWNE, M.D.
MERVYN A. N. CRAWFORD, M.D.
HENRY S. DYER, M.D.
THOMAS H. SILVESTER, M.D.
JOHN AVERY.
WILLIAM HARVEY.
HENRY D. JONES.
JOHN SIMON, F.R.S.
L HENRY SPENCER SMITH.
TBU8TEES OF THE SOCIETY.
JAMES M. ARNOTT, F.R.S.
JAMES COPLAND, M.D. F.R S.
EDWARD STANLEY, F.R.S.
RESIDENT ASSISTANT-LIBRARIAN.
THOMAS WILLIAMS.
FELLOWS OF THE SOCIETY APPOINTED BY
THE COUNCIL AS REFEREES OF PAPERS,
FOR THE SESSION OF 1854-55.
ARNOTT, JAMES MONCRIEFF, F.R.S.
BABINGTON, BENJAMIN GUY, M.D. F.R.S.
BALLARD, EDWARD, M.D.
BALY, WILLIAM, M.D. F.R.S.
BIRD, GOLDING, M.D. F.R.S.
BIRKETT, EDMUND LLOYD, M.D.
BIRKETT, JOHN.
BOWMAN, WILLIAM, F.R.S.
BRODIE, SIR BENJAMIN COLLINS, Babt., F.RS.
BUDD, GEORGE, M.D. F.R.S.
BURROWS, GEORGE, M.D. F.R.S.
BUSK, GEORGE, F.R.S.
CHAMBERS, THOMAS KING, M.D.
COCK, EDWARD.
CURSHAM, GEORGE, M.D.
DICKSON, ROBERT, M.D.
FARRE, ARTHUR, M.D. F.R.S.
FERGUSON, ROBERT, M.D.
FERGUSSON, WILLIAM, F.R.S.
HAWKINS, C^SAR HENRY.
HENNEN, JOHN, M.D.
HILTON, JOHN, F.R.S.
HODGKIN, THOMAS, M.D.
JOHNSON, GEORGE, M.D.
JONES, HENRY BENCE, M.D. F.R.S.
LAWRENCE, WILLIAM, F.R.S.
LEE, ROBERT, M.D. F.R.S.
LOCOCK, CHARLES, M.D.
LUKE, JAMES.
MAYO, THOMAS, M.D. F.R.S.
PAGET, JAMES, F.R.S.
SHARPEY, WILLIAM, M.D. F.R.S.
SOLLY, SAMUEL, F.R.S.
STANLEY, EDWARD, F.R.S.
TRAVERS, BENJAMIN, F.R.S.
WEST, CHARLES, M.D.
A LIST OF THE PRESIDENTS OF THE SOCIETY,
FROM ITS FORMATION.
KI.RCTED
1805. WILLIAM SAUNDERS, M.D.
1808. MATTHEW BAILLDS, M.D.
1810. SIR HENRY HALFORD, Baet., M.D. G.C.H.
1813. SIR GILBERT BLANE, Babt., M.D.
1815. HENRY CLINE.
1817. WILLIAM BABINGTON, M.D.
1819. SIR ASTLEY PASTON COOPER, Bart., K.C.H. D.CL.
1821. JOHN COOKE, M.D.
1828. JOHN ABERNETHY.
1825. GEORGE BIRKBECK, M.D.
1827. BENJAMIN TRAVERS.
1829. PETER MARK ROGET, M.D.
1831. WILLIAM LAWRENCE.
1833. JOHN ELLIOTSON, M.D.
1835. HENRY EARLE.
1837. RICHARD BRIGHT, M.D.
1839. SIR BENJAMIN COLLINS BRODIE, Bart.
1841. ROBERT WILLIAMS, M.D.
1843. EDWARD STANLEY.
1845. WILLIAM FREDERICK CHAMBERS, M.D. K.C.H.
1847. JAMES MONCRIEFP ARNOTT.
1849. THOMAS ADDISON, M.D.
1851. JOSEPH HODGSON.
1853. JAMES COPLAND, M.D. F.R.S.
FELLOWS
OP THB
ROYAL MEDICAL AND CHIRURGICAL SOCIETY
OF LONDON.
EXPLANATION OF THE ABBREVIATIONS.
P. — President. V.P. — Vice-President.
T. — Treasurer. S.— Secretary.
L. — Librarian. C. — Member of Council.
AUGUST 1854.
Amongst the non-residents, those marked thus (*) are entitled by
composition to receiye the Transactions.
Elected
1841 *Jame8 Abeeceombie, M.D., Cape of Good Hope.
1846 *JoHN Abercrombie, M.D., Physician to the General Dis-
pensary, Cheltenham ; Cheltenham.
1851 *Henet Wentworth Acland, M.D. F.R.S., Physician to
the Radcliffe Infirmary, Oxford.
1842 William Acton, Queen Anne-street, Cavendish-square.
1818 Walter Adam, M.D., Physician to the Royal Public Dis-
pensary, Edinburgh.
1851 John Adams, Surgeon to the London Hospital; St. HelenV
place, Bishopsgate-street.
1852 William Adams, Assistant-Surgeon to the Royal Orthopaedic
Hospital; Demonstrator of Morbid Anatomy, St.
Thomas's Hospital ; 5, Henrietta-street, Cayendish-sq.
1818 Thomas Addison, M.D., Physician to, and Lecturer on
Medicine at, Guy's Hospital ; New-street, Spring-
gardens. C. 1826. V.P. 1837. P. 1849. C. 1853.
1814 Joseph Ager, M.D., Great Portland-street, Portland-r
C. 1836.
X FELLOWS OP THE SOCIETY.
Elected
1837 *Ralph Fawsett Ainsworth, M.D., Manchester.
1819 Geoboe Fbedebick Albebt.
1839 RuTHEBFOBD Alcock, K.C.T. K.T.S., China.
1826 James Albebson, M.D. F.R.S., Physician to St. Mary's
Hospital; Berkeley-square. S. 1829. C. 1848. T.1849.
V.P. 1853.
1843 Charles James Bebbidge Aldis^ M.D.> Physician to the
London and Surrey Dispensaries, and Lecturer on
Medicine at the Hunterian School of Medicine ; Chester-
terrace, Chester-square.
1850 Chables Retans Alexanbeb, Assistant-Surgeon to the
Royal Infirmary for Diseases of the Eye ; Cork-street^
Bond-street.
1813 Henby Alexakdeb, F.R.S., Surgeon-Ocuhst in Ordinary
to the Queen, and Surgeon to the Royal Infirmary for
Diseases of the Eye; Cork-street, Bond-street. C. 1840.
V.P. 1850.
1836 Henby Ancell, Norfolk-crescent, Oxford-square. C. 1847.
1817 Alexandeb Anderson.
1820 Thomas Andrews, M.D., Norfolk, Virginia.
1813 William Ankers, Knutsford.
1819 Professor Antommarchi, Florence.
1825 Thomas Graham Arnold, M.D., Stamford.
1819 James Moncriepf Arnott, F.R.S., New Burlington-street.
L. 1826. V.P. 1832. T. 1835. C. 1846. P. 1847.
1817 John Ashburner, M.D. M.R.I.A., 40, York-place, Port-
man-square. C. 1821.
1 85 1 Thomas John Ashton, Surgeon to the Blenheim Dispensary ;
31, Cavendish-square.
1841 John Atery, Surgeon to the Charing-cross Hospital;
Queen-street, May-fair. C. 1854.
1825 Benjamin Guy Babington, M.D. F.R.S., Physician to the
Deaf and Dumb Institution; George-street, Hanoyer-
square. C. 1829. V.P. 1845. T. 1848.
1846 Cornelius Metcalfe Stuart Babington, M.D., Physician
to Queen Charlotte's Lying-in Hospital ; 29, Hertford-
street, May-fair.
1820 *John H. Badley, Dudley.
1838 Francis Badgley, M.D., Toronto, Upper Canada.
FELLOWS OF THE SOCIETY. XI
Elected
1840 W1LLIA.M Bainbbidge, Kingston, Surrey.
1836 Andrew Wood Baied, M.D., Ipswich.
1851 ^Alfred Baker, Surgeon to the General Hospital, Bir-
mingham.
1839 Thomas Graham Balfour, M.D., Royal Military Asylum ;
Chelsea. C. 1852.
1848 Edward Ballard, M.D., Myddleton-square.
1849 Thomas Ballard, Southwick-place, Hyde-park.
1837 William Baly, M.D. F.R.S.» Assistant-Physician to St.
Bartholomew's Hospital; Physician to the Milbank
Prison ; and Lecturer on Forensic Medicine at St. Bar-
tholomew's Hospital; Queen Anne-street, Cavendish -
square. C. 1845. L. 1847. S. 1848.
1847 Andrew Whyte Barclay, M.D., Physician to the Chelsea
Dispensary; Bruton-street, Berkeley-square.
1848 Edgar Barker, Edgeware-road, Hyde-park.
1833 Thomas Alfred Barker, M.D., Vice-President; Physician
to, and Lecturer on Medicine at, St. Thomas's Hospital ;
Grosvenor-street, Grosvenor-square. C. 1844.
1843 Thomas Herbert Barker, Priory-terrace, Bedford.
1847 George Hilaro Barlow, M.D., Physician to Guy's Hos-
pital; Union-street, Southwark.
1 840 Benjamin Barrow, Ryde, Isle of Wight.
1844 William Richard Basham, M.D., Secretary; Physician
to, and Lecturer on Medicine at, the Westminster Hos-
pital ; Chester-street, Grosvenor-place.
1841 George Beaman, King-street, Covent-garden.
1836 William Beaumont, Professor 4)f Surgery in the University
of King's College ; Toronto, Upper Canada.
1840 Charles Beeyor, 41, Upper Harley-street.
1819 Thomas Bell, F.R.S. L.S. and G.S., Vice-President; Pro-
fessor of Zoology in King's College, London ; Lecturer
on Diseases of the Teeth at Guy's Hospital; and
President of the Linnean Society ; New Broad-street,
City. C. 1832.
1847 James Henry Bennet, M.D., Grosvenor-street.
1845 Edwin Unwin Berry, James-street, Coyent-garden.
1820 Stephen Bertin, Paris.
1827 William Birch, Barton, Lichfield.
XU FELLOWS OP THE SOCIETY.
Elected
1845 GoLDiNG BiBD, M.D. F.R.S., Tunbridge Wells.
1850 James Bibd, M.D., Hyde-park-square, Hyde-park.
1849 Edmund Llotd Biekett, M.D., Russell-square.
1851 George Bibkett> M.D., 9, Duncan-terrace, Islington.
1851 John Bibkett, Surgeon to, and Lecturer on Anatomy at,
Guy's Hospital ; 6, Wellington-street, Southwark.
1846 Hugh BiBT, 12, Abbey-road, St. John's-wood; Surgeon to
the Monro Yelhio Hospital.
1843 Patbick Black, M.D., Assistant-Physician to St. Bartholo-
mew's Hospital, and Warden to the Collegiate Establish-
ment at St. Bartholomew's Hospital.
1844 Thomas Blackall, M.D., Physician to the Seamen's
Hospital Ship * Dreadnought ;' Queen-street, May-fair. .
1847 Geobgb C. Blackman, M.D., New York, U.S.
1839 RiCHABD Blagden, Surgeon-Accoucheur, and Surgeon
Extraordinary to the Queen, Surgeon in Ordinary to Her
Royal Highness the Duchess of Kent ; 7, Percy-place,
Walcot-Bath. C. 1847.
1840 Peyton Blakiston, M.D. F.R.S., St. Leonards-on-Sea.
1845 Henby Blenkinsop, Warwick.
1823 Louis Henby Bojanus, M.D., Wilna,
1816 Hugh Bone, M.D., Inspector-Gen. of Hospitals ; Edinburgh.
1810 John Kaye Booth, M.D., Brush-house, near SheflBield.
1846 Peteb Bossey, Thomas-street, Woolwich.
1846 John Ashton Bostock, 34, Clarges-street, Piccadilly.
1849 Edwabd Babons Bowman, M.D., Oxford-terrace, Middleton-
road, Dalston.
1841 William Bowman, F.R.S., Professor of Physiology and
General Anatomy at Ring's College, London ; Assistant-
Surgeon to King's College Hospital, and to the Royal
Ophthalmic Hospital, Moorfields ; Cli£ford- street. Bond-
street. C. 1852-3.
1814 RiCHABD Bbight, M.D. F.R.S., Physician Extraordinary
to the Queen, and Consulting Physician to Guy's Hos-
pital; Savile-row, Regent-street. C. 1821. V.P. 1827.
P. 1837.
1851 Bebnabd Edwabd Bbodhubst, Assistant-Surgeon to the
Royal Orthopsedic Hospital; Brook-street, Grosvenor-
square.
TEiAAfw^ c«r TM fionm". xm
Eleriei
1813 Sn BxxjAMiiE CciLiZFs ^okx. Bki^ D.CX. FJLS^
Scf^ems-SnTScnB xz> "die ^dbeii. Suxscodq in OrdinnT
to ffis EotbI HirtiTM— t IVinee Albox, Fcneisii Cor-
mpcifitdexix of liie liwcjuiu^ of Fnoicse, md Fuieign
AaKkOBte of iiie SotiI Aem^Esasr of Mediane rf Park ;
Scii>-n^, Scecnx-stiwL. C. 1^14. TJ*. 1SI6. P. 1S39.
18i4 CmABUEx Biooxx, B.A. (Caxnaii.; FJLS^ Snrsnin to, and
Lectvrer cm Snr^err bl tlie WcstminBier fiuqpstil ;
1848 WnjxkM Phupot B&ooxxs, ILD^ Sozigecm to the Chd-
tenham Gcneal Hoipatal and JhepeiamrT, and Tisitms
Hedkal Officer to the Cht^xjakbrnm Distziet of Lnnatic
Asrhims; AStnxm booae, Cbdtenham.
1842 Chakles Bl^sxlt Bsoin^, ILB^ PhTsictaii to Queen
Charlotte's LTifi^-in Ho^atal, and St. Geae^'s and
St. lama^M Dispeaarj; HUl-stree^ BedkdeT'fiqDare.
1847 Geosge Bbowx, Grenadier Gvarda' Hoqpita], Bochcater-
row, Wieftmnutcr.
1854 ^Hekkt BmowK, Ssrgeon to H.M. the Qneen, H.B.H.
Prinee Albert, and to the Bojal Hoosehold ; Windaor.
1847 ^BoBEKT BionK, Wincklej-aquare, Preaton, Lancashire.
1851 AucxAXDER Bbowxe, ILD., Army and KaTj dub, St.
James'a-aqiiare.
1827 M. Plekke Bkulatocb, Surgeon to the Hoapital; Bordeanz.
1823 B. Baetlet Bcchanax, M.D.
1843 John Chaeles Bvckstll, M.B., Axminrter, DeTonshire.
1839 Geoege Budd, M.D. F.R.S., Fellow o{ Cains College,
Cambridge ; Professor of Medicine in King's College,
London ; Phjsidan to King's CoU^ Hospital ; Dover-
street, Piccadilly. C. 1846.
1 839 Thoxas Hekey Buegess, M.D., Half-mooD-street, Piccadilly.
1853 Pateick Bueke, 13, Upper Montague-street, Montagae-sq.
1820 Samuel Buekows.
1854 Philip Buebowes, 22, Boyal-crescent, Notting-hill.
1833 Geoege Burbows, M.D. F.B.S., Physician to, and Lecturer
on Medicine at, St. Bartholomew's Hospital ; Cayendish-
square. C. 1839. T. 1845. V.P. 1849.
1837 Geoboe Busk, F.B.S., Surgeon to the Seamen's Hospital
Ship 'Dreadnought;' Croom's-hill, Greenwich. C. 1847.
Xiy FELLOWS OF THE SOCIETY.
Elected
1850 John Stevenson Bushnan, M.D., 49, Salisbary-square.
1818 John Butter, M.D. F.R.S. F.L.S., Physician to the Ply-
mouth Eye Infirmary ; Plymouth.
1851 * William Caboe, All Saints, Norwich.
1851 Thomas Callaway, Assistant-Surgeon and Demonstrator of
Anatomy at Ou/s Hospital ; Wellington-street, South-
wark.
1852 *Oeobge Canney, Bishop's Auckland, Durham.
1842 Henby Cantis, 14, Hanover-street, Hanover-square.
1847 John Buefobb Cablill, M.D., Bemers-street, Oxford-street.
1839 Sib Bobebt Gabswell, M.D., Physician to his Majesty the
King of the Belgians ; Brussels.
1825 Habby Cabteb, M.D., Physician to the Kent and Ganter-
hury Hospital ; Canterhury.
1853 Robebt Bbudenell Cabteb, 11, Terrace, Putney.
1818 *Richabi> Cabtwbight, Pear Tree-cottage, Win wick,
Warrington, Lancashire.
1820 Samuel Cabtwbight, F.R.S., Nizell's-house, near
Tonhridge.
1845 Samuel Cabtwbight, Jun., Old Burlington-street.
1839 William Gathbow, Weymouth-street, Portland-place.
1845 William Oliveb Chalk, Nottingham-terrace, New-road.
1818 RiGHABD Chambeblaine, Kingston, Jamaica.
1844 Thomas King Chambebs, M.D., Physician to St. Mary's
Hospital ; Hill-street, Berkeley-square.
1816 *WiLLiAM Fbedebiok Chambebs, M.D. K.C.H. F.R.S.,
Hardle-house, near Lymington, Hants. C. 1818.
V.P. 1821. P. 1845.
1849 Fbedebiok Chapman, Richmond-green, Richmond, Surrey.
1837 Henby Thomas Chapman, Lower Seymour-street, Portman-
square.
1838 Oeobge Chaplin Child, M.D., Consulting Physician to
the Westminster General Dispensary; Queen Anne-
street, Cavendish-square. C. 1853.
1852 Geobge Boblase Childs, Finshury-place South, Finsbury-
square.
1849 William Fbancis Chobley, M.D., Physician to the St.
Marylebone Dispensary; Stratford-place, Oxford-
street.
FELLOWS OP THE SOCIETY. XV
Elected
1842 William Dingle Chownb, M.D., Physician to the Char-
ing-cross Hospital ; Connaaght-place West^ Hyde-park.
C. 1853.
1839 Frebebioe le Gros Clark, Surgeon to, and Lecturer on
Descriptiye and Surgical Anatomy at, St. Thomas's
Hospital ; Consolting Surgeon to the jiTestern General
Dispensary; Spring-gardens. S. 1847.
1827 Sir James Clark, Bart., MJ>. F;B.S., Physician to the
Queen, Physiciai^ in Ordinary to his Royal Highness
Prince Albert, and Consulting Physician to his Majesty
the King of the Belgians; Brook-street, Grosyenor-
square. C. 1830. V.P. 1832.
1845 John Clark, M.D., Staff Surgeon, 1st class; West Indies.
1848 John Clarke, M.D., Physician to the British Lying-in
Hospital ; 42, Hertford-street, May-fair.
1850 JosiAH Clarkson, Birmingham.
1842 Oscar Moore Passey Clayton, Percy-street, Bedford-
square.
1853 Joseph T. Clover, Mortimer-street, Cavendish-square.
1851 Edward Cock, Surgeon to Guy's Hospital; St. Thomas's-
street, Southwark.
1850 Daniel Whitaker Cohen, M.D., Cleveland-row, St.
James's.
1835 *WiLLiAi|i CoLBORNE, Chippenham, Wiltshire.
1818 Robert Cole^ F.L.S., Holyboume, Hampshire.
1828 John Conolly, M.D. D.C.L., Hanwell, Middlesex.
1840 *WiLLiAM Robert Cooke, Burford, Oxfordshire.
1820 Benjamin Cooper, Stamford.
1819 George Cooper, Brentford, Middlesex.
1841 George Lewis Cooper, Surgeon to the Bloomsbury Dis-
pensary; Woburn-place, Russell-square.
1843 William White Cooper, Senior Surgeon to the North
London Eye Infirmary, to the Honorable Artillery
Company, and Ophthalmic Surgeon to St. Mary's
Hospital; Berkeley-square.
1854 Charles Thomas Coote, M.D., RadcliflFe Travelling Fellow.
1841 Holmes Coote, Secretary ; Assistant-Surgeon to St. Bar-
tholomew's Hospital ; Demonstrator of Anatomy at St.
Bartholomew's Hospital ; Queen-square, Bloomsbury.
XVI FELLOWS OF THE SOCIETY.
Elected
1835 George Ford Copland, Cheltenham.
1822 James Copland, M.D. F.R.S., President^ Consulting
Physician to Queen Charlotte's Lying-in Hospital;
Old Burlington-street. C. 1830. V.P. 1838.
1847 John Rose Cormagk, M.D., Putney, Surrey.
1839 ^Charles Cjesar Corsellis, M.D., Resident Physician to
the Lnuatic Asylum, Wakefield, Yorkshire.
1853 William Gillbtt Cory, M.D., Sutton, Surrey.
1847 Richard Payne Cotton, M.D., Assistant-Physician to the
Hospital for Consumption and Diseases of the Chest ;
46, Clarges-street, Piccadilly.
1828 William Coulson, Surgeon to the Magdalen Hospital,
Consulting Surgeon to the City Lying-in Hos-
pital, and Senior Surgeon to St. Mary's Hospital;
Frederick's-place, Old Jewry. C. 1831. L. 1832.
V.P. 1851.
1817 *SiR Philip Crampton, Bart., F.R.S., Surgeon-General to
the Forces in Ireland ; Dublin.
1841 Mervyn Archdall Nott Crawford, M.D., Physician
to, and Lecturer on Medicine at, the Middlesex
Hospital; Upper Berkeley - street, Portman - square.
C. 1853.
1822 Sir Alexander Crichton, M.D. F.R.S. and F.L.S.,
Physician in Ordinary to their Imperial Majesties the
Emperor and Dowager Empress of all the Russias ; the
Grove, Seyenoaks, Kent. C. 1823.
1847 George Critchett, Assistant-Surgeon to the London
Hospital, and the Royal London Ophthalmic Hospital ;
Finsbury-square .
1837 John Farrar Crookes, Russell-square.
1849 * William Edward Crowfoot, Beccles, Suflfolk.
1851 James Cameron Cummin g, M.D., 1, Cadogan-place,
Sloane-street.
1818 William Cuming, M.D., Professor of Botany at the Glasgow
Institution, and Surgeon to the Royal Infirmary at
Glasgow.
1846 Henry Curling, Surgeon to the Royal Sea Bathing In-
firmary; Ramsgate, Kent.
1 1
FELLOWS OF THE SOCIETY. XVU
EUeted
1837 Thomas Blizabb Cueling, F.R.S., Treasurer; Surgeon to,
and Lecturer on Surgery at, the London Hospital;
New Broad-street, City. S. 1845. C. 1850.
1847 John Edmund Cuebey, M.D., Lismore, Ireland.
1836 Geoeoe Cuesham, M.D., Physician to the Hospital for
Consumption and Diseases of the Chest, and to the
Female Orphan Asylum ; Savile-row, Regent-street.
S. 1842. C. 1850.
1822 Cheistophee John Cusack, Chateau d'£u, France.
1852 Thomas Cutlee, M.D., Physician to the Spa General
Dispensary; Spa, Belgium.
1828 Adolphe Dalmas, M.D., Paris.
1851 Nathaniel John Dampiee, Surgeon to the Farringdon
General Dispensary and Lying-in Charity; Woburn-
place, Russell-square.
1836 * James Stock Daniel, Ramsgate.
1850 John Bampfylde Daniell, M.D., Physician to the Royal
Pimlico Dispensary ; Grosvenor-street, Grosvenor-square.
1820 Geoege Daeling, M.D., Russell-square. C. 1841.
1818 *SiE Feancis Sacheveesl Daewin, Knt., M.D., Breadsall
Priory, near Derby.
1848 Heney Daubeny, 34a, York-street, Gloucester-place.
1846 Feedeeick Davies, Surgeon to the Northern Dispensary;
Upper (Jower-street, Bedford-square.
1818 *Heney Davies, M.D., 6, Duchess-street, Portland-place.
C. 1827. V.P. 1848.
1847 John Davies, M.D., Physician to the Hertford Infirmary,
and Visiting Physician to the County Gaol and Lunatic
Asylum, Hertford.
1853 RoBEBT Coke Nash Davies, Winchelsea, Sussex.
1852 William Davies, M.D., Senior Physician to the United
Hospital, Bath ; Gay-street, Bath.
1852 John Hall Davis, M.D., Russell-place, Fitzroy-square.
1820 Thomas Davis, Spring-gardens. C. 1843.
1818 James Dawson, Liverpool.
1847 Geoege Edwaed Day, M.D. F.R.S., Chandos Professor of
Medicine, St. Andrews.
XVIU FELLOWS OF THE SOCIETY.
Elected
1841 Campbell de Morgan, Surgeon to> and Lecturer on Phy-
siology at, the Middlesex Hospital; Upper Seymoar-
street, Portman-square. S. 1851-2.
1846 "^Samuel Best Denton, Ivy-lodge, Horneea, East Biding,
Yorkshire.
1844 Robert Dickson, M.D., Hertford-street, May-fair.
-1839 James Dixon, Librarian; Surgeon to the Royal London
Ophthalmic Hospital; Green-street, Park-lane.
1845 JohnDodd, 6, Upper Seymour-street, Portman-square.
1853 Robert Druitt, M.D., Curzon-street, May-fair.
1 846 John Drummond, Deputy-Inspector of Fleets and Hospitals ;
Royal Naval Hospital, Chatham.
1843 Thomas Jones Drury, M.D., Physician to the Salop In-
firmary ; Shrewsbury.
1845 George Duff, M.D., Prospect-lodge, Elgin.
1845 Edward Willson Duffin, Langham-place, Portland-place.
1833 Robert Dunn, Norfolk-street, Strand. C. 1845.
1843 Christopher Mercer Durrant, M.D., Physician to the
East Suffolk and Ipswich Hospital ; Ipswich, Suffolk.
1839 Henry Sumner Dyer, M.D., Bryanston-square. C. 1854.
1836 James William Earle, Norwich.
1853 *George Edwardes, Wolverhampton.
1824 George Edwards.
1823 Charles Chandler Egerton, Kendall-lodge, Epping.
1848 George Viner Ellis, Professor of Anatomy in University
College, London.
1854 * James Ellison, M.D., Windsor.
1835 William England, M.D., Wisbeach, Cambridgeshire.
1842 John Eric Erichsen, Professor of Surgery in University
College, London, and Surgeon to University College
Hospital ; Welbeck-street, Cavendish-square.
1815 *Griffith Francis Dorsett Evans, M.D., High-street,
Bedford. C. 1838.
1836 George Fabian Evans, M.D., Physician to the General
Hospital, Birmingham.
1845 William Julian Evans, M.D.
1841 Sir James Eyre, M.D., Consulting Physician to St. George's
and St. James's Dispensary; Brook-street, Grosvenor-
square. C. 1851.
FELLOWS OF THE SOCIETY. XIX
Elected
1844 Arthur Fakee, M.D. F.R.S., Professor of Midwifery in
King's College, London ; Hertford-street, May-fair.
1831 Robert Ferguson, M.D., Physician-Accoucheur to the
Queen, Physician to the Westminster Lying-in
Hospital; Park-street, Grosvenor-square. C. 1839.
V.P. 1847.
1841 William Fergusson, F.R.S., Professor of Surgery in King's
College, London ; Surgeon to King's College Hospital,
and to H.R.H. Prince Albert ; George-street, Hanover-
square. C. 1849.
1852 Alfred George Field, 46, Great Marlborough-street.
1850 *Frederick Field, Birmingham.
1849 George Tupman Fincham, M.D., Assistant-Physician to,
and Lectured on Forensic Medicine at, the Westminster
Hospital, and Physician to the Western Dispensary ;
28, Chapel-street, Belgrave square.
1836 John William Fisher, Surgeon-in-Chief to the Metropolitan
Police Force; Grosyenor-gate. C. 1843.
1838 George Lionel Fitzmaurice, Gloucester-place, Portman-
square.
1842 Thomas Bell Elgock Fletcher, M.D., Physician to the
General Hospital, Birmingham.
1841 Sir John Forbes, M.D. F.R.S. D.C.L., Knt., Physician to
her Majesty's Household; Old Burling^n-street. C.
1852.
1848 John Gregory Forbes, Surgeon to the Western General
Dispensary; Deyonport-street, Hyde-park.
1852 John Cooper Forster, Surgeon to the Surrey Dispensary;
Wellington-street, South wark.
1817 *Robert Thomas Forster, Southwell, Notts.
1820 Thomas Forster, M.D., Hartfield-lodge, East Grinstead.
1816 John W. Francis, M.D., Professor of Materia Medica in the
University of New York, U.S.
1841 John Christopher August. Franz, M.D., Royal German
Spa, Brighton.
1843 Patrice Fraser, M.D., Physician to the London Hospital ;
Guildford- street, Russell-square.
1836 John George French, Surgeon to St. James's Infirmary;
Great Marlborough-street, Regi^nt-street. C. 1852-3.
XX FELLOWS OF THE SOCIETY.
Elected
1849 Robert Temple Fbebe, M.D., Physician-Accoucheur to,
and Lecturer on Midwifery at, the Middlesex Hospital ;
Queen-street, May-fair.
1846 Henry William Fuller, M.D., Assistant-Physician to,
and Lecturer on Medical Jurisprudence at, St. George's
Hospital ; Manchester-square.
1815 *George Frederick Furnival, Egham, Surrey.
1854 Alfred Baring Garrod, M.D., Professor of Materia Medica
and Therapeutics, University College, and Physician to
University College Hospital ; 63, Harley-street, Caven-
dish-square.
1851 George Gaskoin, Cambridge-terrace, Hyde-park.
1819 John Samuel Gaskoin, Clarges-street, Piccadilly. C. 1836.
1819 Henry Gaulter.
1848 John Gay, Finsbury-place, Finsbury-square.
1821 *BicHARD Francis George, Surgeon to the Bath Hospital.
1854 Bernard Gilpin, Belle Vue-house, Ulverstone, Lancashire.
1851 Stephen Jennings Goodfellow, M.D., Assistant-Physician
to, and Lecturer on Forensic Medicine at, the Middlesex
Hospital ; Russell-square.
1818 James Alexander Gordon, M.D. F.R.S., Burford-lodge,
Box-hill. C. 1828. V.P. 1829.
1851 Peter Yeames Gowlland, Finsbury-square.
1844 John Qrantham, Cray ford, Kent.
1850 Henry Gray, F.R.S., Surgeon to the St. George's and St.
^ James's Dispensary ; Wilton-street, Grosvenor-place.
1846 George Thompson Gream, M.D., 2, Upper Brook-street,
Grosvenor-square.
1816 Joseph Henry Green, F.R.S., Consulting Surgeon to St.
Thomas's Hospital; Hadley, Middlesex. C. 1820.
V.P. 1830.
1843 Robert Greenhalgh, M.D., Surgeon- Accoucheur to the
Royal General Dispensary, St. Pancras; 11, Upper
Woburn-place, Russell-square.
1814 John Grove, M.D., Salisbury.
1852 John Grove, Wandsworth, Surrey.
1 849 William Withey Gull, M.D., Assistant-Physician to Guy's
Hospital ; Finsbury-square.
1837 James Manby Gully, M.D., Holyrood-house, Great Malvern.
FELLOWS OF THE SOCIETY. XXI
Elected
1819 Sir John Gunning, Knight, C.B., Inspector of Hospitals;
Paris
1842 Chakles William Gardinek Guthrie, Surgeon to, and
, Lecturer on Surgery at, the Westminster Hospital, and
to the Westminster Ophthalmic Hospital ; Pall Mall East.
1854 Samuel Osborne Habershon, M.D., Demonstrator of
Morhid Anatomy, and Curator of the Museum, at Guy's
Hospital; Physician to the City Dispensary ; 48, Fins-
hury-circus, Finshury-square.
1849 Hammett Hailey, Newport Pagnell, Bucks.
1852 Robert James Hale, M.D., 17, Westhourne-terrace, Hyde-
park.
1842 *Georgb Hale, M.D.
1845 John Hall, M.D., Deputy-Inspector-General of Hospitals ;
Cape of Good Hope.
1848 Alexander Halley, M.D., Queen Anne-street, Cavendish-
square.
1819 Thomas Hammerton, Piccadilly. C. 1829.
1838 Henry Hancock, Surgeon to the Charing-cross Hospital ;
Harley-street, Cavendish-square. C. 1851.
1849 *RiCHARD James Hansard, Broad-street, Oxford.
1848 *George Harcourt, M.D., Chertsey, Surrey.
1836 John Fosse Harding, Mylne-street, Myddleton-square.
1843 Thomas Sunderland Harrison, M.D. F.L.S., Garston-
lodge, Somersetshire.
1846 John Harrison, the Court-yard, Albany.
1841 William Harvey, Surgeon to the Royal Dispensary for
Diseases of the Ear, and to the Freemasons' Female
Charity; Soho-square. C. 1854.
1853 Arthur Hill Hassall, M.D., Physician to the Royal Free
Hospital ; 8, Bennett- street, St. James's.
1828 C^SAR Henry Hawkins, President of the Royal College of
Surgeons of England ; Senior Surgeon to St. George's
Hospital; Grosvenor-street, Grosvenor-square. C. 1830.
V.P. 1838. T. 1841.
1838 Charles Hawkins, Savile-row, Regent-street. C. 1846.
S. 1850.
1848 Thomas Hawksley, M.D., George-street, Hanover-square.
1820 Thomas Emerson Headlam, M.D., Newcastle-upon-Tyne.
XXU FELLOWS OF THE SOCIETY.
Elected
1848 * James Newton Heale, M.D., Physician to the Winchester
County Hospital ; Winchester.
1850 Geoboe Heaton, M.D., Boston, U.S.
1829 Thomas Heberden, M.D., Park-street, Grosvenor- square.
1844 John Hennen, M.D., Physician to the Western General
Dispensary; Upper Southwick-street, Hyde-park.
L. 1848.
1848 Mitchell Henry, Assistant-Surgeon to the Middlesex
Hospital; Harley-street, Cavendish-square.
1849 Amos Henriques, Upper Berkeley-street, Portman-square.
1821 Vincent Herberski, M.D., Professor of Medicine in the
University of Wilna.
1843 Prescott Gardner Hewett, Assistant-Surgeon to the St.
George's Hospital, Lecturer on Anatomy at St. George^s
Hospital Medical School ; Hertford-street, May-fair.
1853 Thomas Hewlett, Surgeon to Harrow School ; Harrow.
1841 *Nathaniel Highmore, Consulting-Surgeon to the Wey-
mouth and Dorsetshire Eye Infirmary; Sherborne,
Dorsetshire.
1814 * William Hill, Wootton-under-Edge, Gloucestershire.
1854 Thomas Hillier, B.A. (Lond.), Resident Medical Officer in
University College Hospital.
1842 William Augustus Hillman, Assistant-Surgeon to, and
Lecturer on Anatomy and Physiology at, Westminster
Hospital ; Argyll- street. Regent-street.
1841 John Hilton, F.R.S., Surgeon to, and Lecturer on Anatomy
at, Guy's Hospital; New Broad-street, City. C. 1851.
1848 Martin Thomas Hiscox, M.D., Bath, Somersetshire.
1840 Thomas Hodgkin, M.D., Bedford-square. C. 1842.
1813 Joseph Hodgson, F.R.S., Westboume-terrace, Hyde-park.
C. 1817. P. 1851.
1835 Thomas Henry Holberton, Hampton, Middlesex.
1843 Luther Holben, 54, Gower-street, Bedford-square.
1814 Sir Henry Holland. Bart., M.D. F.R.S., Physician to
the Queen, and Physician in Ordinary to H.R.H. Prince
Albert; Brook-street, Grosvenor-square. C. 1817.
V.P. 1826.
1846 Barnard Wight Holt, Surgeon to the Westminster Hos-
pital ; Parliament-street, Westminster.
FELLOWS OF THE SOCIETY. XXUl
Elected
1846 Caesten H. Holthouse, Surgeon to the Public Dispensary,
Lincoln's Inn ; Assistant- Surgeon to, and Lecturer on
Anatomy and Physiology at, the Westminster Hospital ;
9, New Burlington-street.
1853 William Chaeles Hoob, M.D., Medical Superintendent,
Bethlem Hospital.
1819 *JoHN Howell, M.D. F.R.S.E., Deputy-Inspector-General
of Military Hospitals ; Honorary and Consulting Phy-
sician to the Bristol Royal Infirmary ; Datchet, near
Windsor.
1828 *Edwaed Howell, M.D., Swansea, Glamorganshire.
1844 Edwin Humby, Windsor- terrace, Maida-hill.
1822 RoBEET Hume, M.D. C.B., Inspector of Hospitals; Com-
missioner in Lunacy; Curzon-street, May-fair. V.P.
1836,
1840 Heney Hunt, M.D., Brook-street, Hanover-square.
1842 Cheistofhee Huntee, Downham, Norfolk.
1849 Edwaed Law Hussey, Surgeon to the Radclifife Infirmary,
Oxford.
1820 William Hutchinson, M.D.
1840 Chaeles Hutton, M.D., Physician to the Royal Infirmary
for Children ; Assistant-Physician to the General Lying-
in Hospital ; Lowndes-street, Belgrave-square.
1838 William Ifil, M.D.
1847 William Edmund Image, Surgeon to the Suffolk General
Hospital ; Bury St. Edmund's, Suffolk.
1826 William Ingeam, Midhurst, Sussex.
1839 Alexandbe Russell Jackson, M.D., Warley Barracks,
Essex.
1845 * Heney Jackson, Surgeon to the Sheffield General In-
firmary ; St. James' s-row, Sheffield.
1841 Paul Jackson, Bentinck-street, Manchester-square.
1847 Thomas Reynolds Jackson, Charles-street, St. James's.
1841 Maximilian Moeity Jacobovicz, M.D., Pesth.
1825 John B. James, M.D.
1847 * William Withall James, Exeter, Devonshire.
1844 Samuel John Jeaffeeson, M.D., Leamington, Warwick-
shire.
1839 Julius Jeffreys, F.R.S., Bath, Somersetshire.
XXIV FELLOWS OF TH£ SOCIETY.
Elected
1840 ^Geckos Samuel Jenks^ M.D., Physician to the Sassex
County Hospital ; Brighton.
1851 William Jenneb, M.D., Professor of Pathological Anatomy
in University College, and Assistant-Physician to
University College Hospital ; Harley-street, Cavendish-
square.
1848 Athol Abchibalb Wood Johnson, Lecturer on Physiology
at St. George's Hospital Medical School, and Surgeon
to the Hospital for Sick Children ; 37, Albemarle-street.
1 85 1 Edmund Chables Johnson, M.D., Sa vile-row, and Arlington-
street, Piccadilly.
1821 Sib Edwabd Johnson, M.D., Weymouth, Dorsetshire.
1847 Geoboe Johnson, M.D., Assistant-Physician to King^s
College Hospital ; Wobum-square.
1837 Henby Chables Johnson, Surgeon to, and Lecturer on
Medical Jurisprudence at, St. George's Hospital;
Savile-row, Regent-street. C. 1850.
1844 John JohnstoiT, Old Burlington- street.
1853 Henby Jones, Soho-square.
1844 Henby Bence Jones, M.D. F.R.S., Physician to St.
George's Hospital ; Grosvenor-street, Grosvenor-square.
1835 Henby Debviche Jones, Soho-square. C. 1854.
1853 Thomas Whabton Jones, F.R.S., 35, George-street,
Hanover-square.
1837 Thomas William Jones, M.D., Physician to the City
Dispensary ; Finshury-pavement, Finsbury-square.
1829 *Geobge Chables Julius, Richmond, Surrey.
1816 *Geobge Hebmann Kauffmann, M.D., Hanover.
1815 RoBEBT Keate, Serjeant-Surgeon to the Queen, Surgeon to
H.R.H. the Duchess of Gloucester; Hertford-street,
May-fair. C. 1818. V.P. 1826.
1848 *Daniel Bubton Kendell, M.D., St.' John's, Wakefield,
. Yorkshire.
1847 Alpbed Keyseb, Norfolk-crescent, Oxford-square.
1839 *David King, M.D., Eltham, Kent.
1851 John Abebnethy Kingdon, New Bank-buildings, City.
1840 Samuel Abmstbong Lane, Lecturer on Anatomy; Surgeon
to the Lock Hospital, and to St. Mary's Hospital ;
Grosvenor-place, Hyde-park. C. 1849.
FELLOWS OF THE SOCIETY. XXV
Elected
1841 *Cha.ele3 Lashmar, M.D., Croydon, Surrey.
1816 6. E. Lawrence.
1809 William Lawrence, F.R.S., Surgeon Extraordinary to
the Queen; Surgeon to St. Bartholomew's Hospital,
and to Bridewell and Bethlem Hospital ; Lecturer on
Surgery at St. Bartholomew's Hospital ; Whitehall-
place, Whitehall. S. 1813. V.P. 1818. C. 1820.
T. 1821. P. 1831.
1840 Thomas Laycock, M.D., York.
1843 * Jesse Leach, Hey wood, near Bury, Lancashire.
1823 John G. Leath, M.D.
1822 John Joseph Ledsam, M.D.
1822 Robert Lee, M.D. F.R.S., Physician to the British Lying-
in Hospital; Physician-Accoucheur to the St. Mary-
lebone Infirmary; and Lecturer on Midwifery at St.
George's Hospital; Savile-row, Regent-street. C. 1829.
S. 1830. V.P. 1835.
1843 Henry Lee, M.D., Eeppel-street, Russell-square. C. 1837.
S. 1839.
«
1843 Henry Lee, Assistant-Surgeon to King's College Hospital,
and Surgeon to the Lock Hospital; Dover-street,
Piccadilly.
1851 George Macartney Leese, Gloucester-place, Portman-
square,
1836 Frederick Leighton, M.D., Frankfort-on-the-Maine.
1854 Hananel de Leon, M.D., 4, Gordon-street, Gordon-square.
1847 John Charles Weaver Lever, M.D., Physician-Ac-
coucheur to Guy's Hospital ; Wellington-street, South-
wark.
1847 Sir John Liddbll, M.D. F.R.S. C.B., Inspector of Hos-
pitals ; Royal Hospital, Greenwich.
1806 John Lind, ^i.D.
1845 William John Little, M.D., Physician to, and Lecturer
on Medicine at, the London Hospital ; 34, Brook-street,
Grosvenor-square.
1819 Robert Lloyd, M.D.
1824 EusEBius Arthur Lloyd, Surgeon to St. Bartholomew's
and Christ's Hospitals; Bedford-row. S. 1827.
V.P. 1838. C. 1843.
XXVI FELLOWS OP THE SOCIETY,
Elected
1820 J. G. LocHEE, M.C.D., Town Physician of Zurich.
1844 Edwabd Francis Lonsdale, Surgeon to the Royal Ortho-
paedic Hospital; Montague-street, Russell-square.
1824 Charles Locock, M.D., First Physician-Accoucheur to
the Queen, and Consulting Physician to the General
Lying-in Hospital ; Hertford-street, May-fair. C. 1826.
V.P. 1841.
1852 Charles Lodge, M.D.
1846 Henry Thomas Lomax, Stafford.
1836 Joseph S, Lowenpeld, M.D., Berbice.
1815 *Peter Luard, M.D.
1852 James Luke, Senior-Surgeon to the London Hospital;
Vice-President of the Royal College of Surgeons of
England ; Broad-street-buildings.
1846 William M'Ewen, M.D., Surgeon to the Cheshire County
Gkiol, and House-Surgeon to the Chester General In-
firmary ; Newgate-street, Chester.
1814 Sir James Macqrigor, Bart., M.D. K.C.B. K.T.S. LL.D.
F.R.S. L. and E., Director-General of the Medical
Department of the Army; Harley -street. Cavendish-
square. C. 1820. V.P. 1815.
1823 George Macilwain, Consulting Surgeon to the Finsbury
Dispensary; the Court-yard, Albany. C. 1829. V.P.
1848.
1839 William Macintyre, M.D., Harley-street, Cavendish-
SQuare. C. 1850.
1848 Frederick William Mackenzie, M.D., Chester-place,
Hyde-park-square.
1818 William Mackenzie, Surgeon to the Eye Infirmary,
Glasgow.
1854 ^Draper Mackinder, M.D., Gainsborough, Lincolnshire.
1822 Richard Mackintosh, M.D.
1844 Daniel Maclachlan, M.D., Physician to the Royal
Hospital, Chelsea, and Deputy-Inspector-Gen eral of
Hospitals ; Royal Hospital, Chelsea.
1851 Samuel Maclean, Brook-street, Grosvenor-square.
1849 Duncan Maclachlan Maclure, Harley-street, Cavendish-
square.
1842 John Macnaught, M.D., Bedford-street, Liverpool.
FELLOWS OF THE SOCIETY. XXVll
Elected
1835 Daniel Chambers Macreight, M.D., St. Hillier*8, Jersey.
1837 Andrew Melville M'Whinnie, Assistant-Surgeon to St.
Bartholomew's Hospital; Lecturer on Comparative
Anatomy at St. Bartholomew's Hospital; Assistant-
Surgeon to the London Hospital for Diseases of the
Skin; Bridge-street, Blackfriars. C, 1851.
1848 William Orlando Markham, M.D., Assistant-Physician to
St. Mary's Hospital ; Clarges-street, Piccadilly.
1824 Sir Henry Marsh, Bart., M.D., Duhlin.
1838 Thomas Parr Marsh, M.D., Physician to the Salop In-
firmary, Shrewsbury.
1851 John Marshall, Assistant-Surgeon to University College
Hospital; 10, George-street, Hanover-square.
1841 James Ranald Martin, F.R.S., Lower Grosvenor- street,
Grosvenor-square. C. 1853.
1849 George Bellasis Masfen, 78, Oxford-street, Manchester.
1853 William Edward Masfen, Stafford.
1818 J. P. Maunoir, Professor of Surgery at Geneva.
1837 Thomas Mayo, M.D. F.R.S., Physician to the St. Marylehone
Infirmary; Wimpole-street, Cavendish-square. S. 1841.
C. 1847. V.P. 1851.
1839 Richard Henry Meade, Bradford, Yorkshire.
1819 *Thomas Medhxjrst, Hursthourne Tarrant, Hampshire.
1837 Samuel William John Merriman, M.D., Physician to
the Royal Infirmary for Children ; Consulting Physician
to the Westminster General Dispensary ; and Assistant-
Physician to the West London Lying-iu Institution ;
3, Charles-street, Westbourne-terrace, Hyde-park.
1852 James Merryweather, 57, Brook-street, Grosvenor-square.
1847 Edward Meryon, M.D., Clarges-street, Piccadilly.
1815 Augustus Meyer, M.D., St. Petersburgh.
1840 Richard Middlemore, Consulting-Surgeon to the Eye
Infirmary, Birmingham.
1854 Edward Archibald Middleship, Richmond, Surrey.
1818 *Patrick Miller, M.D. F.R.S. E., Physician to the Devon
and Exeter Hospitals, and to the Lunatic Asylum ;
Exeter, Devonshire.
1848 Gavin Milroy, M.D., 55, Victoria-street, Westminster.
XXVUl PELLOWS OF THE SOCIETY.
Elected
1852 James Monbo, M.D.^ Sargeon-Major, Coldstream Gaards ;
Vincent-square^ Westminster,
1844 Nathaniel Montefioeb, 4, Stanhope-street, May-fair.
1828 Joseph Moore, M.D., Treasurer; Physician to the Royal
Freemasons' Female Charity ; Consulting Physician to
Queen Charlotte's Lying-in Hospital; Savile-row,
Begent-street. C. 1837.
1836 George Moore, M.D., Hastings.
1848 Charles Hewitt Moore, Surgeon to, and Lecturer on
Anatomy at, the Middlesex Hospital; 35, Montague-
place, Russell-square.
1854 George Moselet, Sandgate, Kent.
1 85 1 Frederick John Mouat, M.lf., Professor of Medicine in the
Medical College of Calcutta, and Secretary of the
Council of Education in India ; Calcutta.
1814 *George Frederick Muhry, M.D., Hanover.
1847 Simon Murchison, Steepleaston, near Woodstock, Oxon.
1845 Thomas D,^utter, M.D., Professor of Surgery in Jefferson
Medicfd College ; Philadelphia.
1840 Robert Nairne, M.D., Physician to, and Lecturer on
Medicine at, St. George*s Hospital; Charles-street,
0^ Berkejey-square. C. 1848. -
1835* Thomas Andrew Nelson, M.D., Nottingham-terrace, New-
roadi^
1843 Edward Newton, Howlaod-street, Fitzroy-square.
1851 James Nichols, Savile-row, Regent-street,
1819 *George Norman, Surgeon to the United Hospital and
Puerperal Charity^; Bath.
1849 Henry Burford Norman, Surgeon to the North London
Eye Infirmary, and the St. Marylebone Dispensary;
Duchess-street, Portland-place.
1845 Henry Norris, South Petherton, Somerset.
1849 * Arthur Noverre, Great Stanmore, Middlesex.
1847 * William Edward Charles Noursb.
1843 William O'Connor, M.D., 30, Upper Montagtierstf^
Montague-square.
1847 Thomas O'Connor, March, CS
1846 Francis Odling, De?oo
FELLOWS OF THE SOCIETY. XXIX
Elected
1822 James Adey Ogle, M.D. F.R.S., CliBical and Aldrichian
Professor of Medicine, Oxford ; and Senior Physician
to the Radcliffe Infirmary ; Oxford.
1850 Heney Oldham, M.D., Obstetric Physician to Guy's Hos-
pital; Finsbury-square.
1842 William Pieks Okmekod.
1846 *Edwakd Latham Ormerod, M.D., Physician to the Sussex
County Hospital ; Old Steyne, Brighton.
1847 William Emanuel Page, M.D., Physician to, and Lecturer
on Medicine at, St, George's Hospital ; Curzon-street,
May-fair.
1847 * William Boxjsfield Page, Surgeon to the Cumberland
Infirmary; Carlisle.
1840 James Paget, F.B.S., Assistant-Surgeon to, and Lecturer
on General and Morbid Anatomy and Physiology at,
St. Bartholomew's Hospital; Henrietta-street, Cavendish-
square. C. 1848.
1806 *Bobsbt Paley, M.D., Bishopston-grange, near Ripon,
Yorkshire.
1836 S. W. Langston Pabkeb, Surgeon to the Queen's Hospital ;
Birmingham.
1847 Nicholas Pabkeb, M.B., Assistant-Physician to the London
Hospital : Microscopical Demonstrator of Morbid Ana-
tomy at the London Hospital School of Medicine;
Finsbury-square.
1841 John Parkin, M.D., Paris.
1851 James Pabt, 7, Camden-road-viUas, Camden-toi9?n.
1828 Bighabd Pabtbibge, F.R.S., Surgeon to King's College
Hospital, and Professor of Anatomy in King's College,
London; New-street, Spring-gardens. S. 1832. C. 1837.
V.P. 1847.
1845 Thomas Bevill Peacock, M.D., Assistant - Physician
to St. Thomas's Hospital; Finsbury-circus, Finsbury-
square.
1830 CjSABLES P. Pelechin, M.D., St. Petersburgh.
1819 John Pbyob Pebegbine, M.D., Jersey.
Thoxab Pebegbine, M.D., Half Moon-street, Piccadilly.
n Ybsalius Pettigbew, M.D., Chester-street, Gros-
•e.
XXXU FELLOWS OF THE SOCIETY.
Elected
1850 George Rofeb, 180, Shoreditch.
1836 Richard Roscoe, M.D., Twickenham, Middlesex.
1836 *Cal£B Burrell Rose, Swaffham, Norfolk.
1850 Archibald Colquhoun Ross, M.D., Madeira.
1849 Charles Hbnrt Felix Routh, M.D., 52, Montagae-sqaare.
1845 Henry Mortimer Rowdon, 29, Nottingham-place, York-
gate, Regent's-park.
1841 Richard Rowland, M.D., Assistant-Physician to the
Charing-cross Hospital ; Woham-place, Russell-square.
1834 Henry Williah Rumsey, Cheltenham.
1845 James Russell, M.D., Physician to the General Dispensary,
Birmingham.
1851 Henry Hyde Salter, M.B., Montague-street, Russell-sq.
1827 *Thoma8 Salter, F.L.S., Poole, Dorsetshire.
1844 *Thoma8 Bell Salter, M.D. F.L.S., Ryde, Isle of Wight.
1849 Hugh James Sanderson, M.D., Upper Berkeley-street,
Portman-square.
1847 William Henry Octavius Sankey, M^D., London Fever
Hospital, Liverpool-road, Islington.
1845 Edwin Saunders, Surgeon-Dentist to the Queen, and
Lecturer on Diseases of the Teeth at St. Thomas's
Hospital; George-street, Hanover-square.
1834 LxjDWiG V. Saxjvan, M.D., Warsaw.
1840 Augustin Sayer, M.D., Upper Seymour-street, Portman-
square.
1853 Maurice Schulhop, M.D., Physician to the Royal General
Dispensary, Bartholomew-close; Suffolk - place, Pall
Mall.
1824 Edward James Seymour, M.D. F.R.S., Charles-street,
Berkeley-square. C. 1826. S. 1827. V.P. 1830.
1840 William Sharp, F.R.S. F.G.S. F.R.A.S., Rughy.
1837 William Sharpey, M.D. F.R.S. L. and E., Professor of
Anatomy and Physiology in University College, London,
and Secretary of the Royal Society ; Gloucester-crescent,
Regent's-park. C. 1848.
1836 Alaxander Shaw, Surgeon to, and Lecturer on Surgery
at, the Middlesex Hospital ; Henrietta-street, Cavendish-
square. C. 1842. S. 1843. V.P. 1851.
1848 *Edward James Shearman, M.D., Rotherham, Yorkshire.
FELLOWS OP THE SOCIETY. XXXIU
Elected
1849 Feancis Sibson, M.D. F.R.S., Physician to St. Mary's
Hospital ; Brook-street, Grosvenor-square.
1848 Edwaed Heney Sieveking, M.D., Assistant-Physician to
St. Mary's Hospital ; Bentinck-street, Manchester-sq.
1839 Thomas Hookham Silvestee, M.D., High-street, Clapham.
C. 1854.
1842 John Simon, F.R.S., Surgeon and Lecturer on Pathology at
St. Thomas's Hospital; Upper Grosvenor-street. C. 1854.
1821 Chaeles Skene, M.D., Professor of Anatomy and Surgery ;
Marischal College, Aberdeen.
1827 Geoege Robeet Skene, Bedford.
1824 Feedeeic Caepentee Skey, F.R.S., Surgeon to, and Lec-
turer on Anatomy at, St. Bartholomew's Hospital;
Surgeon to the Northern Dispensary ; Grosvenor-street,
Grosvenor-square. C. 1828. L. 1829. V.P. 1841.
1838 Heney Spencee Smith, Senior Assistant-Surgeon to St.
Mary's Hospital; and Lecturer on Surgery in the
Medical School adjoining St. George's Hospital ; Sussex-
gardens, Hyde-park. C. 1854.
1835 John Geegoey Smith, Harewood, Yorkshire.
1843 Robeet William Smith, M.D. M.R.I.A.^ Professor of
Surgery in the University of Dublin ; Surgeon to the
Richmond Hospital; DubUn.
1852 Chaeles Case Smith, Senior-Surgeon to the Suffolk General
Hospital ; Bury St. Edmunds, Suffolk.
1845 William Smith, Park-street, Bristol.
1847 William Smith, M.D., Weymouth, Dorsetshire.
1850 William Tylee Smith, M.D., Physician-Accoucheur to St.
Mary's Hospital; Upper Grosvenor-street, Grosvenor-
square.
1843 John Snow, M.D., Sackville-street, Piccadilly.
1851 John Soden, Surgeon to the Bath Hospital; Bath.
1816 *JoHN Smith Soden, New Sidney-place, Bath.
1830 Samuel Solly, F.B.S., Surgeon to St. Thomas's Hospital ;
St. Helen's Place, Bishopsgate-street. L. 1838. C.
1845. V.P. 1849.
1844 Feedeeigk Robeet Sfaceiman, M.B., Harpenden, St.
. Alban's.
1834 James Spaek, Newcastle, Staffordshire.
XXXIV FELLOWS OF THE 80CIET1.
Elected
1851 Robert John Spitta, M.B., Clapham, Sarrey.
1843 ^Stephen Spranger, Grantham, Lincolnshire.
1838 George James Squibb, 11, Montagne-place, Montague-sq.
1815 Edward Stanley, F.R.S., Surgeon to St. Bartholomew's
Hospital; Brook-street, Grosfenor-sqaare. C. 1821.
S. 1824. V.P. 1827. T. 1832. P. 1843. C. 1852-3.
1851 James Startin, Surgeon to the Hospital for Diseases of the
Skin, and Lecturer on Cutaneous Disorders at that
Institution ; Savile-row, Regent-street.
1852 Sherard Freeman Statham, Assistant-Surgeon to Uni-
versity College Hospital ; 43, Mortimer-street, Caven-
dish-square.
1854 Henry Stevens, Resident Medical Officer, St. Luke's
Hospital ; St. Luke's.
1842 Alexander Patrick Stewart, M.D, Assistant-Physician
to, and Lecturer on Materia Medica at, the Middlesex
Hospital; Grosvenor-street, Grosvenor-square.
1843 Robert Reeve Storks.
1844 John Sofer Streeter, Harpur-street, Red Lion-square.
1847 William Allen Sumner, Surgeon to the Portland Town
Free Dispensary ; 25, Wellington-toad, St. John's-wood,
1839 Alexander John Sutherland, M.D. F.R.S., Physician
to St. Luke's Hospital ; Richmond-terrace, Whitehall.
C. 1850.
1842 James Syme, Professor of Clinical Surgery in the University
of Edinburgh ; Charlotte-square, Edinburgh.
1854 *Frederick Symonds, Surgeon to the Radcliffe Infirmary;
32, Beaumont-street, Oxford.
1844 Richard William Tamplin, Surgeon to the Royal Ortho-
paedic Hospital ; Old Burlington-street.
1848 Thomas Hawkes Tanner, M.D., Physician to the Hospital
for Women, Soho-square; Charlotte-street, Bedford-
square.
1840 Thomas Tatum, Surgeon to, and Lecturer on Surgery at,
St. George's Hospital ; George-street, Hanover-square.
C. 1852-3.
1835 John Colley Taunton, Surgeon to the City of London
Truss Society, and to the City Dispensary; Hatton-
garden, Holborn. C. 1840.
FELLOWS OF THE SOCIETY. XXXV
Elected
1845 Thomas Taylor, Vere-street, Cavendish-square.
1852 RoBEET Taylok, M.D., 82, Guildford-street, Russell-square.
1845 *EvAN Thomas, Mauchester.
1839 Seth Thompson, M.D., Physician to, and Lecturer on
Medicine at, the Middlesex Hospital ; Lower Seymour-
street, Portman-square. C. 1849. S. 1850.
1842 Theophilus Thompson, M.D. F.R.S., Physician to the,
Hospital for Consumption and Diseases of the Chest
Bedford-square.
1852 Henky Thompson, Surgeon to the St. Marylebone Dis-
pensary and Infirmary; 16, Wimpole-street, Cavendish-
square.
1835 Fkedeeick Hale Thomson, Clarges- street, Piccadilly.
1819 John Thomson, M.D. F.L.S., Physician to the Finsbury
Dispensary ; Dalby-terrace, Islington. C. 1833. S. 1834.
V.P. 1850.
1850 Robert DuNDAS Thomson, M.D., Professor of Chemistry,
University of Glasgow.
1836 John Thurnam, M.D., Devizes, Wiltshire.
1848 Edward John Tilt, M.D., Physician to the Farringdon
Dispensary ; York-street, Portman-square.
1834 Robe&t Bentley Todd, M.D. F.R.S., Vice-President ; Phy-
sician to King's College Hospital, Professor of Physiology
and of General and Morbid Anatomy in King's College,
London; Brook-street, Grosvenor-square. L. 1842.
T. 1850.
1828 James Tobbie, M.D., Aberdeen.
1843 Joseph Toynbee, F.R.S., Aural Surgeon to St. Mary's
Hospital, Consulting Aural Surgeon to the Asylum for
the Deaf and Dumb, and Consulting Surgeon to the
St. George's and St. James's General Dispensary; Savile-
row. Regent-street.
1850 Samuel JoHif Tbaoy, Surgeon-Dentist to St. Bartholomew's
and Christ's Hospitals; Finsbury-place, Finsbury-
square.
1808 Benjamin Tbavebs, F.R.S., Surgeon Extraordinary to the
Queen, Surgeon in Ordinary to His Royal Highness
Prince Albert ; Green-street, Grosvenor-square. C.
1810. V.P. 1817. P. 1827.
XXXVl FELLOWS OF THE SOCIETY.
Elected
184 1 Matthew TsuHAy, M.D^ Noriand-iqiisre, Notting-hilL
1835 JouK Ccssoii TcBVEEy M.D^ Brighton.
1845 Thomas Tueveb, Surgeon to the Royal Manchester Infir-
mary, and Lecturer on Anatomy; Moaley-st«, Manchester.
1846 Alexandee Uee, Sorgeon to St. Mary's Hospital, and
Consulting Sai^;eon to the Westminster General Dis-
pensary ; ISy Upper Seymour-streety Portman-sqoare.
1819 Baevaed Yan Otem, M.D., Consulting Surgeon to the
Charity for Delifering Jewish Lying-in Women ; 22,
Manchester-square.
1 806 BoTEE Vaux, M.D.
1839 WiLLiAH Randall Vickees, Baker-street, Portman-square.
1810 Jahes Vose.
1828 Benedetto VrLPES, M.D., Physician to the Hospital of
Ayersa, and to the Hospital of Incurables, Naples.
1854 Edwabd Waddington, 2, Guildford-place, Russell-square.
1841 RoBEBT Wade, Surgeon to the Westminster General Dis-
pensary ; Dean-street« Soho.
1823 WiLLiAH Waoneb, M.D., Berlin.
1820 TuoHAS Walkeb, M.D., Physician to the Forces; Monro
Velhio, Brasil.
1852 Walteb Hatle Walshe, M.D., Professor of the Theory
and Practice of Medicine in University College, and
Physician to University College Hospital; 40, Queen
Anne-street, Cavendish-square.
1 85 1 Hbnby Hayneb Walton, Surgeon to the Central London
Ophthalmic Hospital, and Assistant- Surgeon to St.
Mary's Hospital ; Brook-street, Hanover-square.
1852 Daniel Wane, M.D., 20, Grafton- street, Berkeley-square.
1846 Nathaniel Wabd, Assistant-Surgeon to, and Demonstrator
of Anatomy at, the London Hospital; Broad-street-
buildings, City.
1845 Thomas Ogieb Wabb, M.D., Leonard-place, Kensington.
1821 William Tilleabd Wabd, Duncannon-house, Brighton.
1846 James Thomas Wabe, Surgeon to the Finsbury Dispensary,
and to the Convalescent Institution ; Russsll-square.
1811 John Wabe, Clifton, near Bristol.
1814 Mabtin Wabe, Russell- square, Vice-President. C. 1844.
T. 1846.
FBLLOWS OF THE SOCIETY. XXXVll
Elected
1816 *Chable8 Bbuce Wakneb, Cirencester, Gloucestershire.
1829 Elias Tayloe Waeey, Wimbome, Dorsetshire.
1837 Thomas Watson, M.D., Henrietta-street, Cayendish-square.
C. 1840. V.P. 1845. C. 1852.
1847 *Thoma8 Watson, Holbeach, Lincolnshire.
1854 William Webb, M.D., Resident Medical Officer of the
Stafford General Infirmary ; Stafford.
1840 William Woodham Webb, Gislingham, near Thwaite,
Suffolk.
1842 Fbedebick Webeb, M.D., Physician to the St. George's and
St. James's Dispensary; Green-street, Park-lane.
1835 John Websteb, M.D. F.B.S., Consulting Physician to the
St. George's and St. James's Dispensary ; Brook-street,
Grosvenor-square. C. 1843.
1844 William Wegg, M.D., Librarian ; Physician to the St.
George's and St. James's Dispensary ; Maddox-street,
Hanover-square.
1854 Thomas Spenceb Wells, 30, Brook-street, Grosvenor-
square.
1816 Sib Augustus West, Knt., Deputy-Inspector of Hospitals
to the Portuguese Forces; Paris.
1842 Chables West, M.D., Physician-Accoucheur to, and Lec-
turer on Midwifery at, St. Bartholomew's Hospital;
and Physician to the Hospital for Sick Children ;
Wirapole-street, Cavendish-square.
1841 Thomas West, M.D. F.L.S., Daventry.
1828 John Whatley, M.D.
1849 John White, the Albany, Piccadilly.
1852 John Wiblin, 73, Morland-place, Southampton.
1840 Joseph Wickenden, Birmingham.
1824 * William John Wickham, Surgeon to the Winchester
Hospital; Winchester.
1844 Fbedebick Wildbobe, 1) Trafalgar-place East, Hackney-
road.
1837 Geobge Augustus Fbedebick Wilks, M.D., Temple-walk,
Matlock, Derbyshire.
1840 Chables James Blasius Williams, M.D. F.R.S., Upper
Brook-street, Grosvenor-square. C. 1849.
1829 Robebt Willis, M.D., Barnes, Surrey. L. 1838.
i
XXXVm FELLOWS OF THE SOCIETY.
Elected
1839 Ebasmus Wilson, F.R.S., Consulting Surgeon to the St.
Pancras Infirmary ; Henrietta-street, Cavendish-square.
1839 James Abthub Wilson, M.D., Physician to St. (George's
Hospital; DoYer-street, Piccadilly. C. 1846.
1831 William James Wilson, Surgeon to the Manchester
Infirmary; Manchester.
1850 *Robeet Stanton Wise, M.D., Banbury, Ozon.
1825 Thomas Alezandeb Wise, India.
1851 John Wood, 21, Newcastle-street, Strand.
1841 Geoege Leiohton Wood, Surgeon to the Bath Hospital;
Queen-square, Bath.
1848 William Wood, M.D., Kensington-house, Kensington.
1843 John Wabd Woodfall, M.D., Physician to the West Kent
Infirmary; Maidstone, Kent.
1833 Thomas Woemald, Vice-President ; Assistant-Surgeon to
St. Bartholomew's Hospital; Bedford-row. C. 1839.
1842 William Collins Woethington, Surgeon to the Infir-
mary, Lowestoft, Suffolk.
1848 Edwaed John Weight, Kennington-row, Kennington.
[It is particularly requested, that any change of Title or Residence may be
eommunicated to the Secretaries before the 1st of Aagust in each year, in
order that the List may be made as correct as possible.]
F£LLOWS OF THE SOCIETY. XXXIX
HONOEARY FELLOWS.
(Limited to Twelve.)
Elected
1841 William Thomas Bbande, F.R.S.L. and E., Professor of
Chemistry at the Royal Institution of Great Britain ;
Royal Mint^ Tower-hill.
1835 Sir David Brbwstee, K.H. LL.O F.R.S. L. and E., &c^
Cor. Mem. Institute of France, &c. ; Kingussie.
1853 Benjamin Collins Beodie, B.A., Oxford, F.R.S. ; 13,
Albert-road, Regent's-park.
1841 Robert BuowN, D.C.L. F.R.S., President of the Linnean
Society ; British Museum.
1835 The Very Rev. William Buckland, D.D. F.R.S., Dean of
Westminster.
1847 Edwin Chad wick. Commissioner of the Board of Health.
1835 Michael Faraday, D.C.L. F.R.S., Cor. Memb. Institute
of France ; Royal Institution.
1841' Sir John Frederick William Herschel, Bart., D.C.L,
F.R.S., President of the Royal Astronomical Society ;
Somerset House.
1835 Sir William Jackson Hooker, LL.D. F.R.S. L. and E.,
Royal Botanic Garden, Eew.
1847 Richard Owen. F.R.S., Cor. Memb. Institute of France;
Hunterian Professor to, and Curator of the Museum of>
the Royal College of Surgeons of England.
1835 The Rev. Adam Sedgwick, A.M. F.R.S., &c., Woodwardian
Lecturer, Cambridge.
1841 The Rev. William Whewell, D.D. F.R.S., Master of
Trinity College, Cambridge.
xl FELLOWS OK THE SOCIETY.
FOREIGN HONORARY FELLOWS.
(Limited to Twenty.)
Elected
1841 G. Andkal, M.D., Professor in the Faculty of Medicine,
Paris.
1835 Cabl Johan Eckstbom, K.P.S. and W., Physician to the
King of Sweden, First Surgeon to the Seraphim Hos-
pital, Stockholm.
1841 Christian Gottfried Ehrenberg, Berlin.
1835 Baron A. de Humboldt, Member of the Institute of France,
&c., Berlin.
1841 James Jackson, M.D., Professor of Medicine in the Uni-
versity of Cambridge, Boston, U.S.
1843 Babon Justus Liebig, M.D. F.R.S., Professor of Chemistry
in the University of Giessen, &c.
1841 P. C. A. Louis, M.D., Physician to the Hotel-Dieu, Member
of the Royal Academy of Medicine, &c., Paris.
1841 F. Magendie, M.D., Member of the Institute ; Physician to
the Hospital of the Salp^tri^re ; Paris.
1847 Pbofessob Cablo Matteucci, University of Pisa.
1841 JoHANN Mulleb, M.D., Professor of Anatomy and Phy-
siology, and Director of the Royal Anatomical Museum,
Berlin.
1841 Babtolomeo Panizza, M.D., Pavia.
1850 Cabl Rgkitansky, M.D., Curator of the Imperial Patho-
logical Museum at the University of Vienna, &c. &c.
1853 Valentine Mott, M.D., New- York.
1835 C. J. TiMMTNCK, Director of the Museum of Natural History
of the King of Holland, Amsterdam.
1835 Fbedebigk Tiedemann, M.D., Professor of Anatomy and
Physiology, Heidelberg.
1841 John C. Wabben, M.D., Professor of Anatomy and Surgery
in the University of Cambridge, Boston, U.S,
SCROFULOUS CARIES
OF
THE LEFT ASTRAGALUS,
EXCISION— CURE,
WITH FORMATION OF A FRESH JOINT.
BY
S. F. STATHAM,
ASSISTANT-SURGEON, UNIVERSITY COLLEGE HOSPITAL.
Beoeived Nov. Tib, 1858.— Bead Jan. 24th, 1864.
Henry Cudden, set. 5, of strumous tendency, was said
to have had weakness of the left ankle since birth.
At Christmas, 1851, a swelling appeared below the outer
side of the left ankle, which was blistered ; since May he has
been under hospital treatment ; painting with iodine was fre-
quently employed ; latterly the formation of matter pointed
naturally on the inner side, and required opening outside
the joint.
August 25, 1852. — The integument was much diseased
about the ankle ; but on closer examination, and after a week's
rest in the hospital, it was found to be actually implicated only
where corresponding to the situation of the astragalus.
Chloroform being administered, the fistulse were thoroughly
examined. On the outer side the probe reached the surface
xxxvii. 1
2 SCROFULOUS CARIES OF
of the astragalus^ which was exposed and softened^ and there
was a fistula leading backwards by the side of the calcaneum;
on the inner side a probe passed easily along the posterior
face of the astragalus. The ankle-joint was healthy.
Medicines and local applications having been fairly tried
without avails amputation below the knee would probably
become inevitable ; and as his health was already materially
suffering, resection of the astragalus, and of any portion of
the calcaneum that might be necessary was considered jus-
tifiable, if only to be followed subsequently by removal of
the limb.
August 27. — My friends Messrs. Marshall and Glover
assisting me, an incision, three inches long, was carried
along the outer side of the extensor tendons of the toes, and
another to fall into the middle of this one from the outer
side of the foot. The finger found carious disease of the
neighbouring surfaces of the astragalus and calcaneum.
Having lifted up the flaps of the soft parts, and separated
the tendons and vessels in front of the joint in one mass
from the bone, it was sought to release its head, which proving
troublesome, all difficulty was at once removed by cutting
through the neck of the astragalus with the scalpel, and then
by means of the fingers and sequestrum-forceps, the pieces
were dragged out, while the knife freed them from the sur-
rounding parts. During extraction, the posterior portion of
the upper cartilaginous siu*face became separated from the
body of the bone, and was removed later ; this circumstance
much facilitated the operation. The upper surface of the
calcaneum, for its posterior two thirds, was found to be carious,
and was therefore gouged off to a depth of about one eighth
of an inch. The foot hung perfectly loose ; three fingers
could be easily introduced to the bottom of the wound, the
surfaces of the tibia and fibula were sound, the remaining
portions of the tarsus offered no reasons for interfering with
them. It was found that the tendons of the peroneus brevis
and external tendon of the extensor of the toes had been
divided, the lateral ligaments to the calcaneum had escaped,
/ and no vessels required ligature, the profuse haemorrhage
THE LEFT ASTRAGALUS. O
being readily checked by cold water. Lint was introduced
into the cavity of the wound. The same evening a splint was
applied on the inner side of the leg and foot, and a piece of
wet lint laid over the wound ; this was still large and gaping,
as the calcaneum would not enter between the malleoli. The
splint and pad was perforated to allow the escape of any
wound-secretions.
On examination of the bone, the upper articular cartilage
appeared to be unaffected^ but easily separated from the carious
body of the bone beneath. The posterior articulation of the
astragalus with the calcaneum had disappeared. The head
and neck of the bone appeared to be sound.
September Ist. — ^Wound suppurating, health fair. Was
put on iron and nitric acid, later porter; fish, &c. The
foot was never removed from the splint, nor the watery pus
from the cavity of the wound, otherwise than by trickling
water over it, for a whole fortnight.
At the expiration of this time, September 11th, chloroform
being given a third time, the side-splint was changed for one
of tin fitted to the back of the leg and foot. The foot was
found slightly raised on the inner side, otherwise in good
position ; the wound was filled from the bottom and sides by
coarse vascular granulations, not thoroughly united, so that
three passages, admitting a probe loosely, ran to the pos-
terior inner comer of the wound, where a small portion of
the calcaneum was exposed (having apparently escaped the
gouge) ; all other parts of the wound presented to the probe a
softish mass, which it was not attempted to penetrate. The
edges began to draw in and cicatrize, and their neighbourhood
became much improved on the state prior to the operation.
About October 10th, Mr. Erichsen examined the wound,
and found no bone exposed.
October 15th. — By Mr. Erichsen^s advice, ointment of the
nitric-oxide of mercury was used to the edges of the flabby
wound with advantage. The anterior fistula healed, the
posterior one became quiescent. A dextrine bandage was
applied, and the patient discharged.
November 15th. — The wounds were fairly healed.
4 SCROFULOUS CARIES OF
Christmas and Lady-day. — He is going on thoroughly well,
can walk without pain ; there is free mobility of the new
joint, the cicatrix is becoming much firmer and smaller. Till
now a splint has been constantly employed; he may have a
boot fitted. Slight inversion of the foot continues, and the
leg is about one inch shorter than the other.
June 14th. — Mr. Gray, of Cork street, made him a
well fitted boot, the heel raised, an iron support up to the
knee (jointed opposite the ankle to allow limited motion),
with a broad strap around the ankle, and another band below
the knee. The lad is able to walk and run without any pain,
and with merely a halt, partly due to the incumbrance of
the instrument. The foot is perfectly sound ; he can extend
it well, flexion of it on the leg is not so easy, the present
relative position of the parts being more disadvantageous for
this action than before ; its mobility is complete. Inversion
of the foot has disappeared.
I must acknowledge my thanks to Mr. James Turle, the
house-surgeon, for the great care and ability with which he
treated the patient.
A few remarks may be offered on this case; the full
feasibility of the operation was fully established, supposing
the disease to be confined to the astragalus, by the suc-
cess of similar operations occasionally requisite in the after-
treatment of dislocations of that bone. Had the calca-
neum been more diseased than it proved to be, any portion
demanding such treatment would have been removed by
similar incisions, even if it had been necessary, following
Mr. T. Wakley^s example, to excise the whole of that bone.
It is noticeable that no haemorrhage occurred; no important
tendons or ligaments were divided ; and that the recovery is
perfect.
That we may in future be able to restore the sound con-
dition of scrofulous caries of bone is to be hoped for ; at
present we may congratulate ourselves if the excision is
complete, and the functions of the part uninjured. No
other apparatus than a high-heeled boot is now necessary.
THE LEFT ASTRAGALUS. 5
In a case of Liston's^ the astragalus and ends of the tibia
and fibula were removed with success. Other cases of the
removal of single bones of the tarsus for scrofulous caries^
have been, I believe, limited to less important ones than the
astragalus.
Chloroform is a most important agent, as the patient can
be fairly examined, as he should be^ some days before the
operation.
The absolute necessity of not meddling with the parts
after the operation, where interference is uncalled for, may
be well illustrated from Stromeyer on Gun-shot Wounds :
" A young oflScer, whose humerus had suffered comminuted
fracture two-fingers* breadth below its head, and for whom
exarticulation of the part had been first proposed, complained
to me bitterly that his attendant had allowed the first
dressings to remain so long, that maggots had bred in them.
I told him, however, that he must thank this gentleman for
the preservation of his arm.*'
In the dead body of adult males, I have since found that
the astragalus can be removed by clipping off its head by
Listen's forceps, and by dividing the body of the bone back-
wards by the same instrument, so as to cause no kind of
injury to surrounding structures.
On referring to Mr. Dunn's remarkable case, I am no
longer surprised that it is not especially quoted as an
example to follow, as such repeated operations and dangers
from hsemorrhage could hardly allow of success in the
average of cases met with. The excision of the tarsal bones
between the astragalus and metatarsal, viz., of the cuboid
and ext. cuneiform, first, and of the scaphoid and other
cuneiform, later, besides at the later period scraping the
astragalus, and removing the tarsal ends of the second and
third metatarsal — although the patient had four years after-
wards a foot in which ^^ the natural appearance was little
altered," — ^this wholesale excision is certainly a case of won-
derful recovery, but at the same time is certainly — on account
of the destruction of natural connections, and necessary
division of tendons, vessels, &c. — a case which cannot be
6 SCROFULOUS CARIES OF THE LEFT ASTRAGALUS.
quoted otherwise than as an exceptional one. I expect^
therefore, though itself successful, it has actually been of
more harm than advantage to conservative surgery, for few
would like to undertake such an uncertain operation.
I am not aware of excision of the astragalus alone, for
scrofulous disease, having been previously performed.
PATHOLOGICAL REMARKS
ON THE KIND OF
PALPEBRAL TUMOUR
USUALLY CALLED, IN ENGLAND, TARSAL TUMOUR.
BY
H. HAYNES WALTON, Esq., F.R.C.S.,
SURGEON TO THE CENTRAL LONDON OPHTHALMIC HOSPITAL ;
ASSISTANT-SURGEON TO ST. MARY's HOSPITAL.
Received Nov. 28th, 1853.— Read Jan. 24th, 1854.
The subject of tumours of the ocular appendages is
obscurely treated of by writers, more, I believe indeed, than
any in the whole range of ophthalmological literature. The
several stages of the same affection are described as different
diseases, and the same diseases are dissimilarly delineated.
A (jreek and a Latin word bearing the same significa-
tion, — Chalazion and Grando, are applied to different mor-
bid states. The disease I now propose to treat of is involved
in similar perplexity ; for I find it spoken of as " fibrinous
tumour,^^ '' tarsal tumour not encysted,'^ ^^ albuminous tu-
moiur,'^ and by other terms equally erroneous. There is also
disagreement concerning its connection, whether moveable
or not, and even as to consistence, whether hard or soft. I
propose, therefore, in order to be understood respecting the
tumour I mean, to describe the most palpable objective
characteristics, before I point out what appears to be its
pathological condition, and which has not, so far as I am
aware, ever been demonstrated.
Commencing, then, with the external characters, I would
speak of it as a hard, spherical, well-defined tumour, in size
8 PATHOLOGICAL REMARKS ON
yarying from that of a grain of small shot to that of a pea, and
limited to a position on the eyelid corresponding to the space
bounded by the cilia bulbs, and the upper margin of the
tarsus ; that is, corresponding to the position of the meibo-
mian glands, not growing at the edge, and immoveable.
Inadherent to the skin, which may or may not be traversed
by enlarged blood-vessels, being usually solitary, and for the
most part growing on the upper eyelid, yet acquiring the
largest dimensions on the under, where the skin is generally
in the natural state ; not unfrequently giving, on the internal
surface of the eyelid, indication of its existence by a spot of
preternatural redness, and at a later period discoloration, or
even a small fungous growth.
In proceeding now to its pathology, I must at starting
acknowledge the assistance that I have here received from
Dr. Druitt. A very marked example of the tumour on the
upper eyelid in a male, »t, 53, having come under my care
in the summer of this year, I turned the skin aside and
removed it, together with the corresponding portion of the
tarsus, and sent it to him for investigation, as he was at the
time working on the subject of tumours. It may be well,
before I subjoin his valuable report, to state, that the wound
was brought together with sutures, and healed quickly, not
only without disfiguration, but without leaving a scar.
" The tumour,** he says, '' was oval, JJths of an inch in its
length, and ^ths in its short diameter ; having on the one
side the entire thickness of the tarsal cartilage (so called)
with the conjunctiva, on which a few meibomian follicles pro-
jected in the form of yellow granules ; and on the other,
some fibres of the orbicularis. It was evident that the
growth was most intimately adherent to the (so called) tarsal
cartilage. On bisecting it by a clean incision, some viscid,
puriform fluid escaped. On closer examination, the centre
appeared to be constituted by a very clear transparent mem-
branous cyst, almost ^th of an inch in diameter, containing
the aforesaid puriform fluid, and in the very midst, a small
perfectly smooth circular pellet of sebaceous matter. Around
this cyst was a soft pinkish material, and this again was con-
TARSAL TUMOUR. »
tained within a tough fibrous capsule^ continuous with the
fibrous envelope of the (so called) tarsal cartilage/^ He con-
tinues : ^' On making further sections, and examining them
microscopically I perceived — 1st, The conjunctival surface
covered with epithelium, several branches of meibomian
follicles projecting like villi, these follicles being filled with
solid or liquid sebaceous matter, and constituting the yel-
low granular bodies visible to the naked eye. 2d, I
noticed the proper fibrous tissue, commonly called cartilage,
of the lid, the fibres for the most part running parallel with
the conjunctival surface ; it was abundantly permeated by ves-
sels, and contained in spherical loculi, bunches of meibomian
follicles. 3d, These follicles, except that some projected, as
aforesaid, like bunches of currants, on the conjunctival sur-
face were mostly contained in spherical fibrous loculi within
the fibrous membrane. Some contained soft, others hard
matter. 4th, The tumoiu* itself, consisting externally of a
dense, fibrous cyst, continuous with the fibrous tissue of the
lid; vrithin this a layer of fibro-plastic matter, soft, pink,
abundantly supplied with vessels from the fibrous cyst, com-
posed of fibro-plastic cells, with a very little intercellular
fibrillary matter; within this, the thin pellucid cyst above
mentioned, containing a puriform fluid, made up of pus
globules, epithelium cells loaded with oil, and in the centre a
perfectly round pellet of sebaceous matter.^' In conclusion^
he suggests the following to be the order of development :
" 1st, The formation, with a meibomian follicle, of a pellet of
hard sebaceous matter. 2d, The secretion of a more copious
epithelium and fluid matter around. 3d, The addition of
fibro-plastic matter around the obstructed gland follicle, dis-
tending the loculus of fibrous membrane into a cyst.''
Through the liberality of the Museum Committee of the
Royal College of Surgeons, I have been allowed, in conjunc-
tion with Mr. Quekett, to examine two tumours of this
class belonging to the College Museum, whereby the accuracy
of Dr. Druitt's statement is verified, and other facts have
been elicited. It was quite impossible, while these specimens
were in the bottles, to understand them, and the references
10 PATHOLOGICAL REMARKS ON
to them in the Catalogue, is not descriptive. I mention this,
because I have, elsewhere, rather misrepresented them. In
the one^ on the outside of the tarsus from which the skin
and the orbicularis muscle are removed, are two growths,
one very small, too minute, perhaps, to have been recognised
in life, and overlapped by the greater, many sizes larger ;
which, although firmly incorporated with the tarsus, holds
its union by a small base. On the inside of the
tarsus, the site of each is plainly marked by yellowish de-
posits in the course of the meibomian glands. Both
were cut across, and found to contain epithelium scales
and sebaceous matter. I beg to direct attention to the cir-
cumstance that the lesser, which is just enough developed to
admit of a distinctive character, is equally well marked
within the lid as the larger.
The other specimen afforded less definite information, yet
it was peculiar and also instructive. The tumour occupied
the entire upper eye-lid, from which the tarsus had nearly
disappeared. It consisted, on the external or upper surface,
of a dense fibrous sac : on the inside, that is within the lid,
of conjunctiva. The interior, which was irregular and crypt-
like, was, as in the other tumours, filled with epithelium
scales and sebaceous matter. It would seem here, as if the
entire meibomian apparatus had been simultaneously
diseased.
I submit to the Society whether, if they consider the
pathology of the disease to be proved, it would not be judi-
cious to institute the term meibomian tumour, and to adopt
a name alike simple, correct, and significant, an advantage
not often to be met with in the nomenclature of ophthalmic
literature, which is for the most part abominable and
barbarous.
I have often heard it advanced in argument against the
tumour originating in the meibomian glands, that it is always
on the outside of the tarsus. This erroneous statement is
advanced on the false supposition of the situation of these
glands. It has long been pointed out that they are imbedded
in the tarsus ; however, anatomical works state differently.
TARSAL TUMOUR. 11
and describe them as seated between the conjunctiva and it.
The entire glands are within the tarsus^ their ducts even
traverse it, and open on its free margin. The relative ana-
tomy of the parts may to a certain extent be seen with the
naked eye, for if the tarsus be dissected out, the glands will
be equally visible on either side.
It appears to me that the determination of the tumour
outwards, depends on the same law that causes the elimi-
nation outwards of foreign substances from the body, and
includes in its operation the directing of morbid growths to
the surface. That there is occasionally an exception to the
law, the tumour taking an inward direction, and appearing
on the side of the eye-lid, all surgeons engaged in ophthalmic
practice are aware. It then appears in an arrested state,
which may be thus explained. The discoloured spot on the
interior of the eye-lid, above spoken of as giving internal
indication of existence of the tumour, is produced by
absorption of the tarsus, solely, I believe, in consequence of
the pressure produced by the tumoiur on the eye-ball, and
hence the upper eye-lid, as it is more in contact with the
eye-ball, usually exhibits this change earlier and in a more
marked degree. This may not proceed beyond a very limited
extent, but occasionally much of the tarsus is removed when
the determination inward would seem inevitable. With the
removal of the tarsus, the chief and densest covering is lost,
and perhaps as a consequence, there is no deposit of the fibro-
plastic material. The conjunctiva, then the only envelope^
if not interfered with by art, is apt, like the tarsus, to
suffer from absorption and ulceration, allowing the exposure
of the distended follicle, which in turn is similarly affected,
and discharges its morbid contents, or throws out a fungus
growth.
It is well known that meibomian tumours may contain
dissimilar substances, or a mixture of them ; we meet with
glairy, sebaceous, creamy, or purulent deposits; and that
the amount does not always bear an uniform relation to the
size of the tumour, there being sometimes scarcely any fluid
in a very large one, the sac being filled with a solid material.
12 PATHOLOGICAL REMARKS ON PALPIBSAL TUMOUR.
On this point I venture to suggest^ that some of these cha-
racters depend on the changes effected in the fibro-plastic
material that is deposited. For instance, with the onward
development of the plastic material^ white^ or yellow fibroos
tissue is produced^ as in the tumour commonly called poly-
pus ; hence the more solid tumour. Or^ if it degenerate and
undergo retrograde metamorphosis^ the cells are converted
into pus^ or pyoid cells, and the inter-cellular tissue into a
creamy fluid.
p.s. — I desire to say, that since I have adopted the
pathological views above stated, I have, whenever surgical
measures are required, ceased to employ in general the usual
method of attacking the meibomian tumour from the interior
of the eye-lid; but for the most part, that is, when the
tumour takes an outward direction, I divide it on the out-
side, squeeze out the contents, and when it can be accom-
plished, pull away the cyst with a pair of forceps, or if
necessary, remove it by dissection. I am enabled to assert,
that this process is far superior to the other, insomuch as it
is instantaneously effectual. It is not necessary for me to
point out the tediousness and uncertainty of the older
method. I must add, that there need be no fear respecting
the formation of a scar on the eye-lid; for if the incision be
made horizontally, and the edges be brought together by a
strip of plaster, no trace of the operation is left.
NOTICE OF A CASE
OF
SKIN DISEASE
ACCOlifPANIED WITH
PAETIAL HYPERTEOPHY OF THE MAMMARY GLAND.
BY
JAMES ALDERSON, M.D., F.R.S.,
SENIOR PHYSICIAN TO ST. MARY's HOSPITAL ;
ONE OF THE VICE-PRESIDENTS OF THE SOCIETY.
Received Jan. lOth.— Read Feb. 24th, 1854.
The record of an isolated case ought not to be laid before
this Society without sufficient reasons in the way of apology.
In diseases the pathology of which is in a great measure
understood^ and of which fresh knowledge can only be
established by collating the facts of a variety of cases^ the
record of one, or even a few, remarkable incidents can serve
but little to advance our clear appreciation of disease.
It is requisite, therefore, to the value of a single record,
that the disease should be rare ; that the appearances should
have be^n unrecorded ,* and that there should be a satisfac-
tory issue, whether that be of recovery, or of elucidation
through the means of its fatal course affording a subsequent
examination of the nature of the disease and of its relation
to other classes better known.
I conceive that this case includes the earlier-named con-
ditions requisite for the apology. The alarm which the
appearances gave rise to were sufficiently grave to commend
it to our careful examination ; while the favorable issue, if
less calculated than a fatal one to elucidate its history, at
14 NOTICE OF A CASE
least bears with it a certain amount of instruction on the
point of treatment.
The subject of this case was a young lady, set. 20, of fair
complexion, light blue eyes, and fair hair. When I first
saw her, the left breast presented a diseased surface, at the
upper part, to the extent of about four inches in length by
about an inch and three quarters in width. The appear-
ances presented were a perfectly smooth, polished surface, of
an opaque yellowish- white colour, like polished vellum or
ivory ; the margin of the diseased portion was defined by a
strongly-marked border of injected vessels, but on the
polished surface no vascularity could be perceived; there
was no exudation whatever on any part of the breast — ^no
crust or scurf of any kind.
The young lady had noticed the first appearance of this
state of skin twelve months before, when it appeared about
the size of a florin. It had been watched during the interval
by Mr. Cartwright, of Oswestry, and had gradually increased
during the last four months, assuming the appearance I
have now described. The breast itself was larger than its
fellow, and on examination by touch was found to contain
several hard, resisting, nodulated tumours, varying from the
size of a dwarf orange to that of a walnut, one of which
(a small one on the left side) was alone sensible on being
touched. A small enlarged gland was found in the left
axilla, to which an absorbent vessel could be traced from
the breast. The young lady sufiered no pain in the part
aifected, but merely acknowledged to a sensation which she
described as simply reminding her that there was sotnething
there. She was cheerful, and not sufiering any serious
apprehension; her general health was good, the constitu-
tional change only being rather in defect.
Shortly after I first saw her, Mr. TJre joined me in con-
sultation. The following description is quoted from his
very accurate notice of the appearances, as recorded in his
note-book : — " The integument over the upper part of the
left mamma is thickened and indurated, or rather condensed,
in an uniform manner, to the extent of four inches trans-
OF SKIN DISEASE. 15
versely and one incli and three quarters from above down-
wards^ and presents a dull white appearance^ not unlike
parchment ; it is the seat^ occasionally^ of increased heat ;
one of the axillary glands is enlarged. . • . Some of
the lobules of the subjacent glandular structures are enlarged,
and of a more solid consistence than natural. There are
several punctuate elevations of acne indurata over the back
of the neck and shoulders.'^ Mr. Ure was of opinion that
there was partial hypertrophy of the mammary gland, with
interference with the nutrition of the adjacent integument,
connected with the catamenial disturbance.
It was determined to give the patient small doses of
liquor potassse twice daily, in infusion of cloves, and to have
the affected surface pencilled over twice a week with tinc-
ture of iodine. She was recommended to return to the
country for a month.
On her return to London, no progress having appeared
towards recovery to a healthy state of the part, we acceded
to the request of Mr. Cartwright, that Mr. Hodgson^s expe-
rience should be added to the consultation. Mr. Hodgson
compared the appearance to that of a scar left by a blister,
as it appears after death. It is useful to record the im-
pression which the appearance made on different observers.
The vascular margin, which remained as at first seen, would,
however, to my idea, have failed to establish this resem-
blance. The only case which Mr. Hodgson adduced as
bearing any resemblance, was that of a woman, aet. 46, and,
as that case ultimately proceeded to display itself as car-
cinoma, he was led to draw an unfavorable prognostic. With
this. discouraging view of the probable result, he deprecated
the smallest approach to irritation of the part, and recom-
mended a lotion of the diacetate of lead to be substituted
for the iodine, to be applied four or five times in the day ;
the part to be covered with oiled silk. The general treat-
ment was continued, and the patient once more returned
into the country. At this time Mr. Ure's note is as follows :
— " Parchment-like patch, as before, surrounded at its
margin by a narrow faint blush, from capillary injection ;
16 NOTICE OF A CASE
indurated and enlarged lobules of the mammary gland can
be felt in the axillary half of the breast^ and also towards
the sternum^ lying under the patch /^
The diseased surface^ however, continued to increase in
extent, and with its spread the anxiety of friends became
of course more serious. All parties naturally wished for the
first surgical opinion in London, and I felt it right to
comply with the suggestion of the friends, that I should
have an interview with Sir Benjamin Brodie.
In his very large experience, Sir Benjamin Brodie could
only adduce a single similar case — one which had occurred
in the wards of St. George's Hospital, followed by a com-
plete recovery. In that case the skin alone had been
involved. The process of cure had been by throwing oflF of
successive layers of diseased skin, during which the extent
of surface became continually reduced, the skin beneath
ultimately assuming its natural appearance, the patch
becoming smaller and smaller, till it disappeared. Sir
Benjamin Brodie considered the case less allied to carcinoma
than to dry gangrene, since the vessels of the white surface
were apparently destroyed, the injected edge forming a line
of demarcation from which the vellum-like surface might be
thrown o«.
The favorable tendency of the experience afforded by the
former case was corroborated by the fact that at this time
the tumours in the breast were considerably reduced, although
the gland in the axilla and its connecting absorbent vessel
could still be felt.
The general treatment was but little varied. An altera-
tive every other night, with the alkali in liquid extract of
sarsaparilla ; and glycerine was ordered to be rubbed on the
part night and morning.
After an interval of six months we again saw the case.
The surface of the breast had returned to its natural state,
the patient describing that it had faded away gradually.
Similar appearances had, however, shown themselves in
various parts of the person — one on the inside of the left
upper arm and others on the thigh : there was exactly the
OF SKIN DISEASE. 17
same ivory-looking surface^ and the same vascular margin.
Thus all apprehensions subsided of anything more serious
than a simple cutaneous disease^ the alarming concomitant
of the tumours in the breast having been plainly the result
of the delicacy of the organ in which it first appeared.
The progress of the case afforded satisfactory evidence of
the correctness of Mr. lire's first opinion, formed as it was
upon reasoning in the absence of experience. It also
appears to me that, though there was no obvious throwing
off from the edges of the scar, as the curative process anti-
cipated by Sir Benjamin Brodie, yet that this very course of
cure in all probability did take place may easily be supposed,
and that the continued friction by the hand in applying the
glycerine may have gradually removed small portions of the
dead skin from the surface, as they became ready to be dis-
placed by such mechanical means. It is only under some
such supposition that we can understand how a skin so dis-
organised could have reassumed its natural vascular state.
Judging from the result, and from there never having
been any apparently ulcerated surface, Sir Benjamin Brodie
entertained doubts of the correspondence of the disease with
that of the state of dry gangrene, to which he had to a
certain extent compared it in its earlier stage.
This case is at least a rare one, since it has not come
within the observation of men of large experience, and is
not noticed in any works on skin diseases. The characters
are somewhat analogous with those of squamous diseases,
although one of the distinguishing marks of squamous dis-
eases is absent, viz., the red spots with which the eruption
commences. Another peculiarity of some of the squamous
diseases, viz., the commencement of the healing process from
the centre of the diseased surface, did not also occur. The
chief point of similarity is the ivory-like state of the cuticle,
in some degree analogous to a large scale.
To propose an explanation of the progress of the disease,
I should suggest that the extreme vessels of the true skin
appear at some commencing point to have undergone a state
of engorgement. This state of engorgement is distinctly
xxxvii. 2
18 NOTICE OF A CASE OF SKIN DISEASE.
noticed at the margin^ which we may suppose to be an
extension of the original point ; from some cause^ consequent
on the engorgement, the healthy nutrition of the part
appears to have been cut oflF, and the extreme vessels to have
remained incapable of carrying blood. As the portion of
destroyed vessels increased, the engorgement has continued
to spread outwardly around it.
This outward spreading by an enlarged concentric margin
is precisely similar to that of one of the squamous diseases
(lepra). We cannot, however, trace the same process of a
return to a healthy state as we do in lepra, in which last
the renewal commences from the centre, where the disease
originally began. In the case before us the scale remained
entire, and disappeared by an almost imperceptible process.
It is prqbable, had the case been left without local treat-
ment, instead of the diseased cuticle being rubbed oflF by
glycerine, it might have scaled oflF, as suggested by Sir
Benjamin Brodie.
This point remains for future observation, on which
account, as well as that it may be properly classed and
recognised, it is desirable that any recurrence or variety
may be communicated by the members of this Society.
CASE
OF
MOLLITIES OSSIUM,
PRECEDED BY
DEGENERATION OF THE MUSCLES
BY
THOMAS K. CHAiMBERS, M.D.,
PHYSICIAN TO ST. MARY's HOSPITAL.
Received Jan. 26th.— Read Feb. 14th, 1854.
Mary G — was admitted into St. Mary^s Hospital, under
my care, March 26th, 1852. She was twenty-six years of
age, unmarried, and had never been able to follow any
avocation, on account of weak health. She was about four
feet ten inches high, and six stone seven pound! in weight,
not emaciated, and of symmetrical figure. A waxy, yellow
complexion, with bright scarlet colour in her cheeks, gave
her the aspect of a delicate person. No history of hereditary
disease of any kind could be elicited from herself, or from
enquiries made at her native village. The ankles were
(edematous, and she walked slowly, as if from languor, on a
flat surface ; when she attempted to ascend steps or to raise
herself from a stooping posture, defective power in the
muscles of the haunch and thigh became very evident. The
flesh of the whole body was exceedingly soft and flabby, the
calf hanging down in the baggy way that it does in emaciated
persons. She stated that she had first become an invalid
seven years previously, her illness commencing by weakness
and pain across the loins, especially at the end of the short
ribs on the left side. The same symptoms had continued,
with occasional variations, up to the date of admission. She
20 CAS£ OF
usually felt worst in early springy and got better during
summer and autumn. The bowels were somewhat costive ;
the catamenia generally regular^ but occasionally postponed
for a fortnight beyond the customary time. The urine,
examined on admission and frequently while she was in the
hospital, was variable in quantity, and variable in specific
gravity, in proportion to its quantity, from 1'020 to 1'028.
It was sometimes neutral, rapidly turning alkaline; but
generally acid, depositing a considerable sediment of lithate
of ammonia, soluble in heat. In all cases, boiling imme-
diately threw down a cloud of phosphates, soluble in mineral
acids, and showed the absence of albumen.
With the exception of a stitch under the short ribs of the
left side, caused by turning in bed, and a sense of great
debility in the back on standing, there was no pain expe-
rienced at any time, either with or without pressure.
The patient remained in the hospital, taking steel, for
five weeks, without any change in the symptoms except the
disappearance of oedema and improvement of appetite ; after
which she left at her own desire. She returned in three
weeks, and again remained under observation for ten days,
when she was advised to go to the seaside, and left with the
expressed intention of doing so. During her residences at
St. Mary^s, the bones of the back and limbs had been care-
fully examined several times, without any deviation from the
natural state being discovered, except that the ribs on the
right side, viewed from behind, were not quite symmetrical,
being more prominent than the left. On her going away,
I told her of the difficulty experienced in arriving at a
diagnosis, and desired her to let us know when any medical
man could discover the nature of her complaint.
From St. Mary^s she went to St. George's, and was under
the care of Mr. Cutler for about six weeks ; after which she
left at her own desire. The symptoms continued? equally
obscure at St. George's, and no diagnosis of the case was
formed till one night spontaneous fracture of the left femur
occurred. She was then removed to her home, at Islip,
Oxfordshire, and placed under the care of Mr. Blick. She
MOLLITIES OSSIUM. 21
informed him of the wish I had expressed to learn the result
of the case, and through his kindness I am enabled to detail
the remainder.
It appears that when he saw her on the 11th of August^
1852, a fortnight after leaving St. George^s, fracture of both
femora had taken place in the upper third of the bones.
Obtuse angles were formed at the seat of fracture, by the
thighs being drawn upwards and outwards, and twisted on
themselves, so that the external border of each foot lay on
the bed, and the soles approximated to one another. The
only parts of the lower extremities capable of voluntary
motion were the toes. The shin-bones felt soft on pressure,
producing a sensation to the finger described by Mr. Blick
as like that of a fibro-cartilaginous tumour. She breathed,
ate, drank, slept, excreted faeces, urine, catamenia, as well as
usual; taking meat, wine, and beer, but refusing medicine.
She had no pain, except when the tumefied parts about the
fractured ends of the bones were touched, and those were
excessively sensitive. No important change seems to have
occurred — except that the body kept shortening, and the
leg-bones getting softer, so that the foot could be raised
three or four inches from the bed without altering the posi-
tion of the knee — ^till April, 1853, when the right arm be-
came painful to the touch and paralytic.
In May, the same misfortune happened to the left upper
extremity also.
In June, the pelvic arch gave way, the mons veneris being
drawn upwards and the anus thrust forwards, the alse of the
ossa ilii falling inwards.
In July, the ribs on the right side gave way, and she
began to suffer much from dyspnoea and cough, with quick
pulse, fever, and restlessness.
In August, the bones of both arms were found quite soft.
In September, the ribs on the left side fell in, and she
was now much distressed by increased dyspnoea and palpita-
tion of the heart. The contractions and dilatations of that
organ were distinctly visible through the fleshy parietes. The
lower jaw and bones of the skull also felt soft on pressure.
22
CASE OF
Towards the end of October the distortion of the lower
parts- of the trunk was so great, that the fseces could not be
naturally expelled, and had to be removed by mechanical
means.
She at last died of dyspnoea, on the 6th of November.
Several times during the illness, Mr. Blick sent me some
of the urine secreted by Mary G — . It presented always
very similar physical characters to that passed in St. Mary's.
Whilst acid, the microscope showed a great quantity of lithate
of ammonia, vesical epithelium, and a few crystals of oxalate
of lime. After it became alkaline, there were to be seen in
it a number of yellow spherules, some of them furnished
with thorn-like processes, which Dr. Hassall informs me he
considers to be uric acid in combination with an earthy base.
There was also a large quantity of vesical epithelium, nume-
rous crystals of triple phosphate, and a few stellse, pro-
nounced by Dr. Hassall to be phosphate of lime. A quan-
titative analysis of this urine, by Dr. Beale, gave the following
result :
Urine of Mary G — .
Water 97100
Solid Matter 28-10
Healthy Urine (Berzelius).
. 93300
. 67-00
Urea
Extractives
Lithic Acid
Earthy Phosphates .
Fixed Alkaline Salts .
In 100 Parts of Solid Matter.
17-7
36-3
0-6
3-3
41-9
44-7
39
1-4
1-4
25-9
It will be seen, therefore, that the solid matters of the urine
were diminished below the natural standard by more than
half, and that this diminution was due to deficiency of animal
matter; that the alkaline and earthy salts were nearly dou-
bled in amount, the principal comparative augmentation
taking place in the earthy phosphates.
After death, the body was found to have shrunk from four
MOLLITIBS OSSIUM. 23
•
feet ten to three feet one inch and a half, and could be rolled
up upon itself, to use Mr. Blick^s forcible expression, *' like an
ill-stuffed bolster/^ No examination of the viscera was made,
but portions of the tibia, sartorius, and rectus femoris muscle
were removed, and a sharp instrument passed into many
parts of the bony skeleton, which was found universally soft
and unresisting.
The section of tibia sent to me was of the colour of muscle,
soft and friable throughout, presenting to the knife scarcely
more resistance than brain, and retaining its shape solely
by the aid of the tough periosteum. No remains of bone
could be felt except on cutting the periosteum, where a slight
grittiness was perceived on making a section with sharp
scissors for microscopical examination. Under the micro-
scope, the whole of the bone, to within half a line of its ex-
ternal surface, was seen to consist of large fat-vesicles, con-
taining, some white, others a reddish oil, and thus accounting
for the colour of the texture, with the intervals between
them filled up with spherules of various magnitude, mostly
about as large as blood globules, of a dull red tinge. They
were formed apparently of aggregated grains, and some had
an indistinct nucleus. No fibrous structure could be de-
tected in this situation.
The part next to the periosteum, which felt gritty when
under the scissors, exhibited, when examined under a
quarter-inch lens, small islands of opaque bone, which, how-
ever, did not retain a perfeotly healthy appearance ; the bone
corpuscles being indistinct, and the caniculi not to be dis-
cerned. These islands were surrounded by some structure
more transparent, and that again bounded by a reddish
fibrous structure, in which were oil globules of various sizes,
and a few oval fat-vesicles towards the inside. The addi-
tion of hydrochloric acid caused a slight disengagement of
gas.
The portion of rectus muscle was, to the naked eye, of the
natural colour, but of too homogeneous an appearance. Under
the microscope, it presented no traces at all of fibrous structure,
or even linear arrangement. It had become a mere con-
24 CASE OP
•
genes of fat-vesicles^ the interspaces between which were
filled up with globular granular corpuscles of various sizes^
estimated by Dr. Seiveking as from ^ths of an inch in
diameter. Many of the larger had a granular nucleus.
The circumstances which have induced me to lay this case
before the Society are the following :
Ist. The portrait which is afforded of an early stage of
the disease — a stage at which it is rarely the subject of ob-
servation.
2d. The impression produced by it upon my mind that
the degeneration of the bones was preceded by that of the
muscles — ^that the degeneration of the two tissues was depen-
dent^ in this instance^ on the same crasis^ and the probability,
therefore, that such is its history in other cases also.
3d. The opportunity of placing on record a careful quan-
titative analvsis of the urine in this disease.
4th. The fact of the degeneration being least advanced
in the external circumference of the bone.
5th. The formation of perfect fat vesicles in both bone
and muscle.
As respects the symptoms which precede the known
softening of the bones, attention may be called to the absence
of those rheumatic pains which are usually stated to be pre-
cursors, nay by some supposed to be the actual causes of the
malady. When the disease is fairly established, these pains
may conjecturally be referred to the pull which healthy
muscle exerts on the periosteum) deprived of its usual firm
base of resistance. But, as in the case before us, the muscle
appears to have yielded first to the morbid influence, it did
not strongly contract, did not drag on the periosteum, and
so no pains of consequence were experienced. We see, also,
that previous to the softening being demonstrated to exist,
the same appearances were noted in the urine which were
observed when the disease was fully established, pointing to
a great probability that the chemical constitution was not
dissimilar. We see also that the degeneration was purely
automatic, not arising as a consequence of any other morbid
state, nor, as far as could be ascertained, of an hereditary taint.
MOLLITIES OSSIUM. 25
That the degeneration of the muscles preceded that of the
bones is of course a matter of opinion. A person observing
the circumstances only after deaths would naturally suggest
that it was due to their necessary inertness for so many
months. But the condition of the patient during her stay
at St. Mary's discountenances this idea. The mechanism
of the bones was complete so far as their ordinary uses de-
mand, yet so peculiar was the partial paralysis, or rather
torpidity of fibrous contraction, that, in spite of the rarity of
the disease, I was induced to select fatty degeneration of the
muscles as the only explanation I could give.
As respects the quantitative analysis of the urine, it is
confirmatory of the suspicion usually expressed, though not
hitherto proved, that a great loss of lime takes place through
this channel.
The observation that the degeneration was least advanced
in the external surface of the bone, shows that its course is
from within outwards ; and that, therefore, till the shell of
osseous structure bends or breaks, the bone is as useful as
ever for the purposes of muscular motion. The mere thin-
ness of the plate of bone remaining intact can make no
difference mechanically to the action of the muscles im-
planted in it, so Jong as it is strong enough to bear the
strain. It will be seen that this last argument has an im-
portant bearing on the first observations made concerning
the early diagnosis of the disease.
ON THE
KELOID OF ALIBERT,
AND ON
TRUE KELOID.
BY
THOMAS ADDISON, M.D.,
PHYSICIAN TO guy's HOSPITAL.
lleceived Feb. 16th.— Read Feb. 28th, 1854.
The term keloid, or kel'Oide, the name given to the sin-
gular affections of the integument about to be described,
has been variously interpreted ; some deriving it from KriXtf^
a tumour ; others^ in reference to certain supposed resem-
blances^ from yii\v9 a crab's claw; or from x^Xvc, a tortoise;
whilst others, apparently with much greater propriety, derive
it £rom KriXig, ' quasi ustione facta macula/ the disease in
every instance presenting a greater or less resemblance to
some one of the diversified effects left by a burn.
The more immediate object of this very slender commu-
nication, is to show that the keloid originally described by
Alibert, and now so generally recognised, is altogether dif-
ferent in its mode of development, character, and progress,
from another disease occurring in the same tissue, and to
which, with much greater aptitude, the term keloid may be
applied, if we are to regard resemblance to the effects of a
burn as its correct interpretation ; for I think it will be
shown, that whilst the keloid of Alibert and others can
hardly be regarded otherwise than as a fibrous tumour deve-
loped in the subcutaneous areolar tissue, the other form of
disease to which I have alluded, although originating in the
same tissue, is of a character and leads to consequences
28 KELOID OF AXIBEKT^
widely different. In order^ however^ to illastrate and confirm
this proposition^ it will be necessary to give a description of
both diseases ; and in so doings I will, as far as possible^ avoid
trespassing too much upon the time and attention of the
Society.
I propose distinguishing the two diseases in question by
the terms " Keloid of Alibert/' and " True Keloid.''
KELOID OF ALIBERT.
I have given the name " Keloid of Alibert*' to this form of
disease^ because I believe Alibert to have been the first to
discriminate and accurately describe it. In his celebrated
work^ ' Description des Maladies de la Feau/ will be found
a very accurate representation of it^ executed with all the
artistic skilly and perhaps a little of the exaggeration of
colourings for which that work is so remarkable. He there
suggests its holding a middle place between what he so vaguely
fmd indiscriminately calls '^dartre'' and cancer^ and was
led in consequence to give it the name of " cancroide/' like
cancer; farther justifying the appellation, however, hj com-
paring, as others have done, the claw-like rays or processes
of the extending disease to the claws of a crab. Since the
period of Alibert's original publication^ several other writers
have furnished cases and commentaries to illustrate the
character, progress, or pathology of the disease. Amongst
these we find the names of Biett, Yelpeau, Cazenave, Coley,
and others ; but by far the most complete and elaborate essay
on the subject has only lately been written by Dr. Dieburg,
of Dorpt, and published in the ' Deutsche KliniV at Berlin,
and for a knowledge of which I am indebted to my colleague
Mr. Birkett and Dr. Whitley.
The keloid of Alibert first appears in the form of very
small, hard, shining, tubercular-looking elevations, of a round-
ish or oval shape^ somewhat firmly set, of a dusky or deep
red colour, and generally attended with itching or pricking,
shooting or dragging pains in the part. These tumours
slowly increase until they attain a height of two or three
AND OF TRUE KELOID. 29
lineSj and comprise an area varying from that of a horse-bean
to that of a small almond. So long as they continue to be
abruptly prominent^ the summit, or even the entire surface
of each tumour, instead of remaining uniformly red, not
unfrequently presents a pale or blanched appearance, as if
from pressure of the increasing tumour upon the cutis
situated above it, and which might at first sight be mistaken
for some sort of fluid effusion. On close inspection, how-
ever, it is found, that so far from this being the case, the
tumour displays a hardness, firmness, and elasticity, which
almost convey the notion of so much fibro- cartilage, to
which indeed it has been not unaptly compared. After an
uncertain period, these hard shining tumours become broader,
of more irregular outline, and occasionally slightly depressed
in the centre. At this time, and sometimes even earlier, by
the aid of an ordinary magnifying glass, or by the naked eye,
delicate whitish tendinous-looking lines may be perceived,
stretching across the surface of the tumours, mingled with
minute blood-vessels of a bluish, purplish, or pinkish colour.
The extension of each individual tumour now seems to be
effected by certain tapering claw-like processes of seldom
more than from half a line to a line in breadth, and probably
from a quarter of an inch to as much as an inch in length,
proceeding from the edges or angles of the expanding tumour.
These claw-like processes appear to produce a puckering of
the skin ; and, as it were, draw the healthy integument into
which they pass, towards the original excrescence, and within
the influence of the local changes ; appearances, nevertheless,
which are probably the mere consequences of the stretching
and dragging of the integument occasioned by the increasing
size of the tumour beneath.
The slow and gradual increase of these tumours may
proceed for months or years, and at last attain a size of
an inch, an inch and half, or two inches in length, as much as
half an inch or an inch in breadth, and probably an ele-
vation of three or four lines above the level of the sur-
rounding skin. There may be but a single tumour, or there
may be several : when more than one, they may be congre-
80 KELOID OF ALTBERT^
gated together in the same neighbourhood^ or may occupy
parts of the integument remote from each other : when of
the largest size^ the tumour may so stretch and attenuate
the integument as actually to protrude beyond it, exposing a
red shining excoriated looking surface. The development of
the tumour is occasionally preceded or accompanied by heat,
and some degree of puffiness or tumefaction of the surround-
ing parts^ but without redness or other discoloration ; a state
of things, indeed^ which may temporarily supervene at any
period of the disorder, either in consequence of some acci-
dental cause of general excitement, some irritation applied
to the tumours themselves, or spontaneously, and without any
very appreciable cause whatever.
From the very commencement, as has been already ob-
served, the disease is attended with itching and pricking
sensations, which, as the former increases, are aggravated to
a sense of constriction, or to severe pricking or stabbing
pains, which prove extremely distressing to the patient.
Under such circumstances, pressing or handling the tumour
is loudly complained of; the sufiferings of the patient, if a
female, are not unfrequently such as to harass her during
the whole of the day, and almost completely to deprive her of
rest at night.
The morbid deposit which essentially constitutes the
keloid of Alibert, takes place in the subcutaneous areolar
tissue, between the cutis and adipose membrane. The
occasional heat and tumefaction of the neighbouring integu-
ment, as well as the itching pain and redness of the tumour
itself, sufficiently attest that the morbid process is at least
accompanied by a degree of vascular excitement nearly
allied to inflammation, an inflammatory state which, it would
appear, gives rise to a certain amount of adhesion amongst
the meshes of areolar tissue around ; and, as we know that
tumours of considerable size may be developed in the sub-
cutaneous areolar tissue without either uneasiness, pain, or
any very obvious change in the appearance of the skin itself,
I am inclined to attribute to this accompanying inflammatory
and adhesive process, the fixed condition of the tumour, the
AND OF TRUE KELOID. 31
great vascular injection of the superincumbent skin, and the
intensity of the local pains, as well as those remarkable puc-
kerings of the integument which attend the increase of the
tumour, and constitute the claw-like processes from which
some have derived the name " keloid/^
The disease most frequently attacks females from the age
of 18 to 35 or more, and in a large majority of instances is
found situated near the sternum, between or upon the
mammse ; it nevertheless occasionally afiFects the male, and
in both sexes has been known to occur on other parts of the
body, as the arms, shoulders, neck, belly, or even the head
or face. AUbert, as already observed, considered it in
some way allied to cancer ; an opinion unsupported by any
facts with which I am acquainted; whilst others, with
perhaps no better evidence, have attributed the predisposi-
tion to a scrofulous taint. The development of the disease
in different parts of the integument at the same time, or in
succession, and its almost certain recurrence after extirpa-
tion by the knife or by caustics, clearly point to some
peculiar constitutional condition ; but what that condition is
remains to be ascertained. All that we at present know
respecting the exciting cause of the disease, amounting to
no more than the fact, that, instead of arising spontaneously,
on parts to all appearance previously sound, as is com-
monly the case, it has not unfrequently been observed to be
developed upon and apparently excited by a cicatrix, as of a
bum, a boil, or a recent wound, such as that inflicted by the
punishment of flogging. To the disease, when occurring
under the latter circumstances, Alibert, in a subsequent
work, applied the term spurious or false keloid — the cicatrix
keloid of Dieburg — a form of the complaint, however, which
is sometimes altogether painless.
Case i. (PI. 158^^ Model 231^^ 231^^)1 reported by Mr.
Pratt. — Susannah Black, set. 18, a single person, who has
been residing with her mother, at Snowsfields, was admitted
on the 6th October, 1853, having been transferred from
^ The references are to plates and models in Guy's Hospital Museum.
82 KELOID OF ALIBERT,
No. 6, Mary, by permission of Dr. Babington, under whose
care she had been since the 14th ult.
She is below the middle height ; has dark hair, eyes, and
complexion ; a narrow forehead and heavy expression ; but
seems intelligent and is highly hysterical, and was formerly
apprenticed to a laundress, but not strong enough to con-
tinue this occupation.
Her catamenia first appeared at the age of 15, and have
recurred regularly since, generaUy continuing about three
days, but with pain in the back and loins, and during the
last two years with clots, sometimes of the size of a shilling.
Her father died of diseased heart, but the other members
of her family are healthy, and none of her relations have
ever suffered as she now does.
She is marked by the smallpox, which she had when
three or four years old, but does not look unhealthy, and
states that she was always in good health until about two
years ago, when, from exposure to cold at Gravesend, while
lightly clad, she first became ill, with pain in her head and
right side, and at the scrobiculus cordis, shooting thence to
the back. Six weeks after this, in Berkshire, having been
gradually getting worse in the meanwhile, with loss of appe-
tite and increase of pain, which for a time was so severe as
to keep her in a bent position, but occasionally left the
scrobiculus cordis and appeared in the loins, she suddenly
vomited about a pint of dark clotted blood, after which she
became better, but did not lose the pain in her back, and
suffered from palpitation of the heart. About three months
after this, having returned to London in the interim, the
vomiting of blood recurred, and from this time was repeated
at intervals, sometimes of two or three months, at others of
two or three weeks only, until a few days before admission;
and once in the hospital, about two weeks since, she brought
up a teacupful of blood.
About twelve weeks since she had a gathering in her
right breast, which discharged a small quantity of matter;
two weeks after, and just as this was healing, her neck,
chest, and both breasts swelled a good deal, with a dull
AND OF TRUE KEI^OID. 33
aching pain^ but without oedema; one week after this, or
two or three days after the swelling had subsided, she
first noticed two small red pimples on the right breast,
at its upper and inner part, which were painful, with a
pricking sensation, and tender. Then, about one week
after, two other similar raised spots, appeared on the left
breast, at about the same position, but not symmetrical,
and then two smaller ones above these ; these all gradually
increased in size ; but in varying degrees, and, as they did
so, at certain stages of their existence became white (?)
There are at present two raised spots on the right breast,
nearly oval in shape, and of considerable size ; four on the
left breast, two large and two small ; one on the upper part
of the sternum ; several at the upper part of the abdomen ;
and one on the left shoulder; and a cluster of equivocal white
spots at the lower part of the back on the right side.
They seem to be in every stage of existence ; some small^
red or white; others of varying size, more vascular, gene-
rally of a red colour, and marked with small venae, and
traversed by peculiar white lines; but they all change
colour occasionally (?) from white to red or even purple,
and have a peculiar, firm, and unyielding feel. They have
always a dull and aching sensation, converted into a more
acute pricking pain by pressure; are more or less raised above
the level of the surface, the largest as much as one eighth of
an inch, or even more ; have irregular margins, much resem-
bling the contraction of a cicatrix, and appear to increase in
size by an extension of the white lines which traverse them
into the surrounding tissue, like feelers, to which, indeed,
their irregular margins are due.
Her chest is well formed, her nutrition good; she seems
to be subject to boils ; has old cicatrices of venesection on
each arm, and a small hard nodule on the left side of the neck,
just above the sterno-clavicular joint, resembling an enlarged
gland. Her tongue is white and moist; her pulse 80, full
and regular; her counteuance rather flushed; her bowels,
which have been much relaxed, now act about three times
daily, the motions being very loose ; her appetite is bad ;
XXXVII. 3
34 KELOID OF ALIfiEKT^
she complains of pain in her head^ across the top. The
sounds of respiration and of the heart are normal^ as well
as the resonance of the chest on percussion^ but the hearths
impulse is strong and heaving, and the pulsations of the
aorta felt above the sternum.
Case ii (Model 229, pi. 158^^ pi. 158^), furnished by
Mr. Whateley, surgeon, of Berkhampstead. — William Garrett,
ddt. 37, applied to me, about May, 1851, with a small
tumour on the skin of the left breast, slightly elevated above
the surrounding skin, silvery red in appearance, exquisitely
tender, and about one inch in diameter. I recommended
its removal, to which he would not then consent. On seeing
him about a month afterwards, there was a second appearing,
about an inch from the first, and subsequently a third. Such
being the case, and fearing that others might still appear, I
did not think it advisable to press the operation. He was
then sent to Guy^s Hospital, at the request of the late
Bransby B. Cooper, Esq., in order that a model, &c., might
be taken of the tumour in its then state.
After remaining some time, he again came into the
country, and was under my care at the West Herts. Infirmary.
The tumour still continuing to grow, and the three having
coalesced into one, and having no appearance of any fresh
growth in the neighbourhood, I again advised an operation,
to which he consented, and I removed it on the 10th of May,
1852, removing with it about a quarter of an inch of the
sound skin all round, and fully down to the bone. The
wound was dressed with warm water dressing and oil-silk,
and was cicatrized. The cicatrix is now sound, and the
man in good health.
The tumour, when freshly cut through, in structure,
colour, and appearance most nearly resembled a cow^s udder.
The slight sketch. No. 4, represents the result of a micro-
scopic examination of the tumour, made, however, under
very unfavorable circumstances, by Dr. Habershou, of Guy^s
Hospital.
A more minute and careful examination of a keloid
AND OF TRUE KELOID. 35
tumour has been supplied by Dr. Dieburg, of whose account
of it the following is a translation :
'' On section we observe a dull white colour, a dense
tissue in which fibrous structure is visible to the naked eye,
and a creaking sound is produced by the knife. On pressure,
no fluid exudes in most cases ; in a few, a watery fluid is seen,
sometimes reddened by blood. This is characteristic, as
difi^rent from the 'tumores verrucosi cicatricum' of C.
Hawkins, from which a peculiar fluid may generally be ex-
pressed. Microscopical examination shows the diff*erent
stages of development of the cells and fibres. We distin-
guish — 1. More or less rounded bodies, the largest 0*05 of
a millimetre; in their interior, we see a nucleus, and fre-
quently other molecules. 2. Cells elongated in the direction
of one of their diameters, in great numbers : they seem to
constitute a characteristic element of all the tumours of
'cicatrix-keloid' (spurious keloid of Alibert). These cells,
called by FoUin ' elliptical bodies,' are rounded at their
extremities, and their sides present central bulging. These
cells are about 0*01 millimetre in breadth, and 0*06 in
length. They contain a nucleus easily distinguishable by
its brightness from the dull surrounding parts. 3. Spindle-
shaped bodies, bulging in their centre, and having long, waving
appendages. 4. Fibres of cellular tissue and elastic fibres.
The fibres of cellular tissue are formed into bundles, which
cross each other, and constitute a pretty dense web. The elastic
fibres are less numerous and larger than the latter, and are
not easily seen without immersion in acetic acid. When
a slice of keloid in an early stage of development is placed
under the microscope, it is found to consist almost entirely
of the spindle-shaped bodies; at a somewhat later period
these are seen to have lost their nuclei, and assumed a
fibrous appearance : this is most frequent. At a still later
period, we see distinct fibrous, bundles, crossing each other,
and by immersion in acetic acid, the elastic fibres become
visible. The whole is nourished by a comparatively small
number of blood-vessels. The surface is covered by a very
thin layer of epidermis, consisting of tesselated cells, very
36 KELOID OF ALIBERT^
closely pressed together^ which require softening before thejr
become visible under the microscope.^
>}
The following translation from M. Labert^s ' Traite prac-
tique des Maladies Cancereuses, et des affections curables^
confondues avec le Cancer/ will probably not be considered
out of place.
^* Among the cases of spontaneous and multiplied
keloid that we have observed, there were two especially
curious, in consequence of their multiplicity and extent.
In one case, under M. Velpeau, at "La Charite,'' the
whole pectoral region of one side was covered with these
tumours; many of which were sufficiently large to have
reddened and eroded the surface of the skin at their borders.
^' In the second case, a child set. IO5, had a very great
number of keloid tumours, developed upon its back, red on
their surfaces, and which had formed in the cicatrices which
were consecutive to numerous applications of caustic potash,
applied to the poor child by a charlatan, who promised to
cure, by this method, a scrofulous disease under which the
child laboured.''
I may add to this passage from Lebert, the fact, that
I have myself very recently been consiilted in the case of a
young lady of about eighteen years of age, upon whose back,
shoulders, and breast, I counted as many as thirty keloid
tumours. I was told that they originated in the cicatrices
of boils which broke out about six or seven months before.
From the situation, it had been a case probably of acne.
In regard to treatment little can be said. Various in-
ternal and external remedies have been tried in vain ; and
when extirpated by the knife or destroyed by caustics, the
disease has, I believe, very generally returned on the seat of
the original disease. When, however, the disease has been first
developed in a cicatrix — the spurious keloid of Alibert — ex-
tirpation has proved more successful^ the disease not having
again made its appearance in several instances. It has indeed
been asserted that the keloid tumour may subside sponta-
neously, leaving behind a white and depressed cicatrix ; but I
AND OF TRUE KELOID. 37
believe this to be extremely rare, and is in itself a very im-
probable event, after the tumour has attained any consider-
able size.
TRUE KELOID.
What I have ventured to call " True Keloid^' presents a
very remarkable character, and leads to much more serious
consequences than the keloid of Alibert. It is a disease,
too, which, so far as I know, has not hitherto, with the ex-
ception of a slight allusion of Dr. Coley, been either noticed
or described by any writer. Like the keloid of Alibert, it
has its original seat in the subcutaneous areolar tissue, and
is first indicated by a white patch or opacity of the integu-
ment, of a roundish or oval shape, and varying in size from
that of a silver penny to that of a crown piece, very slightly
or not at all elevated above the level of the surrounding
skin, and probably unattended, in the beginning, with pain
or any other local uneasiness or inconvenience, although a
more or less vivid zone of redness surrounding the whole
patch, or a certain amount of venous congestion in its imme-
diate vicinity, sufficiently attests the vascular activity or
inflammatory process going on in the parts beneath. Occa-
sionally, and especially when the original white patch is of
considerable diameter, its surface presents here and there a
faint yellowish or brownish tint communicating to the whole
spot a somewhat mottled appearance. The slow and in-
sidious change taking place in the areolar tissue either
stops and the spot disappears, or it proceeds, and at length
begins to declare itself by a feeling of itching, pain, tight-
ness, or constriction in the affected part, and frequently by
a certain amount of subcutaneous hardness and rigidity,
extending beyond the site of the original superficial patch,
although as yet without any necessary change in the ap-
pearance of the superincumbent skin. This hardness and
rigidity can be distinctly felt, and, especially when situated
on the extremities, may sometimes be traced along the course
of the neighbouring tendons or fasciae, or stretching like a
38 KELOID OF ALIBERT,
cord along the limb^ so as to bend or shorten it, and even
interfere with natural progression. At length the part
originally affected becomes more or less hide-bound, and a
similar change taking place around the more superficial
fasciae and tendons, the latter become so tightened, fixed, and
rigid, as to be no longer capable of performing their proper
functions, and to such an extent, that the whole of a limb,
but especially the fingers, may be permanently contracted,
bent, and rendered almost as hard and immoveable as a piece
of wood ; thereby impeding progression, distorting the gait,
and making the patient, a poor miserable cripple for the
remainder of his life.
As these changes proceed, the patient continues to expe-
rience itching, pain, or a sense of tightness or constriction
of the parts, till at length the disease begins to tell upon
both cutis and cuticle. The skin, which may have pre»
viously presented only a slightly drawn or puckered look,
imparting, to a greater or less extent of it, a ray-like
appearance, now shrinks or shrivels; it assumes a dry,
smooth, or glistening aspect; it undergoes a more decided
change of colour, becoming reddish, pinkish, yellowish, or
of a dead leaf colour ; the cuticle exfoliates ; the cutis mani-
fests a tendency to superficial ulceration or excoriation, with
consequent scaliness or scabbing, or, when not excoriated,
is occasionally surmounted by obscure tubercular or nodular
elevations — ^the whole appearance very closely resembling
the remains of an extensive and imperfectly cicatrised bum.
From some part of the boundary of the discolored and
shrivelled skin, there may now and then be seen reddish,
elevated, claw-like processes, of from half an inch to two
inches in length, extending into the sounder integument,
and bearing a very exact resemblance to those mentioned as
being so characteristic of the keloid of Alibert. It must
also be observed that, during the progress of the disease, it
is by no means uncommon to find, scattered over various
parts of the apparently sound surface, certain oval or
roundish and flattened tubercular-looking elevations, which
are somewhat hard to the touch, about the size of a split
AND OF TRUE KELOID. S9
pea or horse-bean^ and without any other discoloration than
what appears to be the result of accidental friction or
irritation.
The above description of true keloid clearly points to
some morbid change slowly taking place in the subcutaneous
areolar tissue, whilst the itching, pain, and uneasiness expe-
rienced by the patient, the red zone surrounding the patch,
and the injection of the neighbouring veins, as well as the
subsequent appearances presented by the parts affected,
would indicate that the morbid process going on in that
tissue is one very nearly allied to inflammation, probably of
a strumous kind. It would also appear that the inflamma-
tory product, by its subsequent contraction, seriously inter-
feres with the proper nutrition of the cutis, fixes it more or
less firmly to the parts beneath, and, when deposited in the
immediate neighbourhood of fasciae and tendons, may,
probably, after the lapse of months or years, lead to
all those serious inconveniences which I have already de-
scribed.
I will not abuse the patience of the Society by entering
into any speculations respecting the origin and essential
nature of this very singular disease ; neither is it necessary
to dwell upon plans of treatment, further than to observe
that, with the exception of iodine, none of the many reme-
dies tried, seemed, in extreme cases, to make the slightest
impression upon either the appearance or the progress of the
disorder. In one instance, however, less advanced, iodine,
taken internally, with the simultaneous application of iodine
ointment to the affected parts, did appear to arrest the advance
of the local changes, and somewhat lessen the rigidity of the
affected tendons. Whether the preparations of iodine ad-
ministered at a very early period of the disorder would
prove more effectual, I have had no opportunity of ascer-
taining, although I am inclined to entertain a strong opinion
in its favour.
The following case presents an example of the disease in
its earlier stages :
40 KELOID OF ALIBERT^
Case hi (Models 222, 228, 224, PI. 158^*), reported by
Mr. Towne. — Eliza Watkins, a young woman between 19
and 20 years of age, of ruddy complexion, fleshy and well
looking, with light eyes, and hair tending to red, presented
herself amongst the out-patients of Guy^s Hospital early in
June last.
She was in the situation of lady^s-maid, and had for some
time been residing at Cheltenham. Her general health was
good, and at this time apparently undisturbed. She had
been suffering from pain and stiffness in the left arm and
left leg, for which she was now seeking relief.
The first appearance of the disease had been noticed
twelve months previously, when a small white spot, about
the size of a shilling, was observed on the left side ; but, as
neither pain nor inconvenience accrued, no anxiety was felt
with reference to it until about eleven weeks prior to her
appearance at the hospital, when she first became sensible of
pain, attended with a dragging sensation in the left arm and
left leg, both limbs being affected simultaneously. Medical
assistance was now called in; poppy fomentations were
ordered, and for some time persisted in; the disease still
making slow but steady progress.
The lady with whom she was living, having occasion to
visit London, brought the young woman with her, and took
the opportunity of having a second opinion. The case was
now treated as a sprain ; but the patient, not feeling satisfied,
determined to come to the hospital.
The two limbs were in a very similar condition. At this
time they presented to the eye but slight indications of the
disease, which principally consisted in a hard, drawn, tight
look, on the limb being extended; there might, however, be
felt, through nearly the whole length of both arm and leg,
a rigid band, which gave to the touch the impression of
some inelastic substance tightly strained under the integu-
ment.
The shoulders presented a mottled appearance, and had
several whitish patches interspersed with numerous small
tubercular-looking growths. There also existed a chain of
AND OF TRUE KELOID. 41
spots which nearly surrounded the right nipple, and several
.others about the neck and breasts. The spot on the left
side (described as the first appearance of the disease) had
now attained the size of a five-shilling piece, and had thrown
out a band upwards towards the cartilage of the ribs, and a
second descending towards the pubes.
During the second week in August, I again saw the
patient. The pain in the arm and leg had much increased,
with " a feeling of shortenings^ in the limbs affected ; and,
after sitting for some time, it was with difficulty the foot
could now be extended. The band down the arm had
become more distinctly expressed, had assumed a slightly
tendinous and glistening character, and had thrown out
several small lateral processes. A fresh spot had appeared
on the upper lid of the left eye, and a second on the outer
side of the right leg. Those on the shoulders had become
more evident ; the larger one had increased in size, become
yellowish in colour, glazed on its surface, was hard to the
touch,%nd did not move freely with the surrounding inte-
gument.
The next case exemplifies a more advanced stage of the
disease :
Case iv (Model 225, PI. 158^), reported by Mr. King.
— Louisa Burston, set. 11, was admitted, under Dr. Addison,
December 8th, 1852.
The patient, who is a very strumous-looking subject, was
very strong and healthy as a baby, but was noticed to be
slightly ricketty when she began to walk ; this was between
eighteen months and two years of age ; but when she was
three and a half or four years old she had nothing remarks
able about her.
From this time her mother always considered her deli-
cate; but, beyond frequent attacks of ophthalmia, which
have deprived her of most of her eye-lashes, and appear to
have been of a strumous character, she has never suffered
any decided illness.
Attention was first directed to the right thigh, about
42 KELOID OF A LIBERT^
fourteen months ago^ on account of complaints on the part
of the child of itching in that situation ; and this appears to
have been so intense^ that measures were taken, by tying
her hands^ Sec,, to prevent her flaying herself. When first
examined^ red spots, like flea-bites, were observed thickly
studding the inner part of the thigh, about its middle third,
but not imparting any feeling of elevation to the finger.
This condition lasted about a fortnight, and was then
succeeded by a flaky desquamation of the cuticle, which
persisted for two months, during which time the itching
continued to be almost intolerable, and when the part was
scratched the spots before alluded to would reappear. About
or soon after this time the part began to feel thickened,
puckered, and hard, and graduaUy assumed its present
appearance.
On the right thigh, about one inch below Poupart's liga-
ment, and nearer the spine of the pubes than the crest of
the ilium, commences this singular appearance of the skin,
which more nearly resembles the scar left by a burb than
anything else. There is a strip, about one inch broad,
nodulated and irregular on its surface, and discolored in a
peculiar manner, being partly red, with a predominance of a
light brown tint.
This strip of disease proceeds down the thigh, following
the course of the sartorius muscle as far as the junction of
the upper two thirds with the lower third of the thigh, at
which point the most marked discoloration of the skin
ceases ; but it is found, by examination with the finger,
that the same condition of the cellular tissue follows the
sartorius to its insertion, and also appears to involve the
tendons of the internal hamstring muscles.
In the lower part of the same leg the cellular tissue over
the anterior part of the ankle appears to have become
involved, and, in particular over the internal malleolus, the
integument is firmly attached to the bone.
She has at the present time no peculiar sensation in
the affected parts, nor is the use of her leg in walking at all
impaired.
AND OF TRUE KELOID. 43
Since she has been in the hospital she has taken various
medicines^ without the slightest perceptible effect.
The next is an instance of the disease in its most aggra-
vated form, reported by Dr. CoUingwood. (Model 228, 227,
pi. 158^^ 158^.)
Elizabeth Alexander, set. 12, resides at EUirfield, in
Hampshire, where her father follows the occupation of
shepherd. She has a comfortable home, plenty of whole-
some food, and attends the village school. The following
account is given by the gentleman under whose care she
has been for some years.
"When I first saw Elizabeth Alexander she was about
4 years old, and was a robust, healthy child, and has been
in good health up to the present time. When nine months
old, she, whilst crawling about the house near the fireplace,
touched a piece of hot iron with the left arm, between the
elbow and wrist, which soon healed up, leaving a slight scar,
not so large or deep as that produced by vaccination, and to
my own knowledge she has had no other bum or scald.
When seven years old she had a mild attack of measles, which
was so slight that she was not confined to her bed for a day,
and perfectly recovered from it. A few months after the
measles, she had a white spot appear on her left side, below
the breast, about the size of a fourpenny piece, with a
brownish, hard, inelastic state of skin, about the size of a
five shilling piece, surrounding the white spot, and looking
as though the skin had been scorched with hot iron, and I
asked the question if such had been the case, and was
assured by both mother and child that it was not ; and in a
few weeks I found the brown part of the skin extending to
a large circumference, very much more thickened, puckered,
and inelastic, giving no pain on pinching up the skin, or on
pressure. About six months after, a similar spot made its
appearance on the left shoulder, and from a note I made of
the case twelve months after, the following were the appear-
ances then presented.
" The shoulder had been affected for a year and a half.
44 KELOID 07 ALIBERT^
About a year and a half ago a white spot appeared upon the
shoulder^ surrounded by a brownish discoloration^ just as
though it had been touched with a hot iron^ not painful or
tender to the touch ; it has gradually extended itself around
the shoulder joint and down the upper third of the arm ;
the skin is shining^ hard^ and puckered^ like the cicatrix
from a bum^ and the deltoid and other muscles of the
shoulder are so diminished as to leave no appearance of their
form ; the skin thickened, and apparently adhering to the
bone, with considerable loss of power and motion, and con-
traction of the arm.
"About eighteen months after, the hip (left) became
affected exactly in the same manner as the side and shoulder.
Two years after this, the right shoulder was the seat of
mischief of the same nature as that already existing in the
other regions."
From the above account, then, it appears that the dis-
ease commenced in the left hypochondriac region, next
attacked the left shoulder, then the left hip ; up to this
time, upwards of four years from the first appearance of the
disease, the riffht side was unaffected, while nearly the
whole of the left side was contracted by it. About a year
before her admission the right shoulder became the subject
of this singular disease, and, on a careful examination I dis-
covered upon her right thigh a small patch of puckered skin
about as large as a sixpence, the right leg and thigh being
otherwise free. Of the existence of this small patch the
patient was ignorant, which was suggestive of its being the
commencement of the disease in a hitherto sound part ; but
on careful watching, for a period of several weeks, it does
not appear that it has increased in size, but rather to have
diminished, and the patient affirms that whereas the disease
has steadily increased as a whole, individual spots or small
patches have made tlieir appearance for a short time and
have receded again.
On November 10th, 1852, she was admitted into Guy's
Hospital, Lydia 18, under Dr. Addison, when she presented
the following appearances. The right shoulder is contracted,
AND OF TRU£ KELOID. 45
hard, and tuberculated, the miiscles are wasted^ and a strip
of skin^ about one inch and a half wide^ extending from the
back of shoulder to the inner part of the elbow, is bound to
the bone. This part was formerly ulcerated, and the only
part which ever was so. It now presents a scaly appear-
ance, and is very hard. The left shoulder is more tuber-
culated, and more hide-bound, but the disease on this side
is more confined to the shoulder proper, and does not extend
far down the arm. On the front of each shoulder is a
considerable patch, but the chest is otherwise free. Both
the elbow joints are tightly contracted, and permanently
bent at nearly a right angle, and the forearms and hands
are considerably wasted. The fingers are nearly all bent
inwards, and the hands are small, like those of a child six
or seven years old.
From the lower angle of the scapula, a semilunar patch
(the original disease) runs round to the mesial line, half way
between the umbilicus and the nipples. A large irregular
patch exists on the left side, immediately below the
umbilicus.
The outside of the left thigh is affected throughout its
whole length, together with the whole of the left buttock ;
the left calf is wasted, and measures two inches in circum-
ference less than the right, while the right thigh measures
two inches and three quarters more than the left. The
left foot is contracted, and the ankle stiff; the toe is pointed
downwards, and she walks upon the ball of the toe.
The right thigh is free &om the disease, except a small
irregular discoloration about as large as a sixpence, on the
front of the thigh. These hard shining places have
diminished sensibility, and never were painful. None other
of the family ever was affected with the same disease. Her
general health is excellent.
Case of Keloid disease. Furnished by John Birkett,
Esq., surgeon to Guy^s Hospital. (Models 220, 221, pi.
158^^)
E. K — , aet. 81, a female, was born in Devonshire, lived
46 KELOID or ALIBERT^
some years in the couDtry^ but the greater part of her life
has been passed in the suburbs of London.
She married at the age of 15 years and 8 months^ was
confined with her first child at 16 years and 8 months^ and
never menstruated until after her marriage. She has given
birth to eight children^ all of whom she suckled with both
breasts^ although most with the left.
Of regular and temperate habits ; she has of late sub-
sisted^ since the death of her husband^ by working a mangle.
She has always enjoyed good healthy with the exception
of palpitation of the heart ; and her aspect was formerly
healthy. At present she is pallid and careworn^ from anxiety^
and a scanty means of subsistence.
I first saw this patient in July^ 1851, through the kind-
ness of Dr. Bossey, of Woolwich^ who had watched the
case.
In December, 1850, and whilst suckling her last infant,
she felt an acate pain under the right arm^ and observed a
curious appearance in the skin of the part.
Now, July, 1851 — six months from the discovery of the
disease — ^it occupies a surface of about six inches by three
in extent. It is situated on the axillary half of the right
mamma, and extends into the right axilla. The skin feels
rigid, as if the tissues were of the nature of parchment. It
exhibits a peculiar corrugation, resembling that state of the
integuments known as '^cutis anserina,'^ in an exaggerated
condition. It is of a peculiar dull, yellowish tint, resembling
that of ivory. The part is painful ; often there is numbness,
and at other times sharp, tingling, shooting pains. The
right nipple is retracted — more than usual, for it has never
been so well developed as the left.
A patch of the same disease, about one inch square, is
developed in the skin of the left axilla.
In the summer of 1852, a third patch was developed, in
the skin of the inside of the left arm.
At present — and I saw her in January, 1854— the diseased
patches of skin have but little changed their appearances.
They have all increased a little, they all give her more or
AND OF TRUE KELIOD. 47
less pain^ and no treatment hitherto adopted has produced
any beneficial result.
The patch on the right breast and axilla is longer ; the
nipple is deeply retracted, indeed invisible, and the gland
atrophied. She is much more obese than when I first saw
her, and her general health is very good.
The application which seemed to afford her the most relief
was the liquor plumbi diacet. dil.
Second Communication.
ON THE
BLOOD AND EFFUSED FLUIDS
IN
GOUT, RHEUMATISM, AND BRIGHT'S DISEASE.
BY
ALFRED B. GARROD, M.D.,
PROFESSOR OF MATERIA MEDICA, THERAPEUTICS, AND CLINICAL MEDICINE,
AT UNIVERSITY COLLEGE ;
AND PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL.
Received March 10th.— Read March Uth, 1854.
In February, 1848, I had the honour to communicate to
the Society a paper on the condition of the Blood and
Urine in Gout, Rheumatism, and Bright^s Disease, which
appeared in the volume of the ' Transactions' for that year ;
I now offer one intended as supplementary to the first, and
introductory to a third paper, which I hope in a few weeks
to bring before your notice.
The principal points established in the first paper having
reference to the subject matter of the present communication
are as follow :
!• The discovery of uric acid in the blood.
2. Its existence in very minute quantities, mere traces,
in healthy human blood, and in that of some of the lower
animals, as the duck.
3. Its augmentation in that fluid in certain pathological
conditions of the habit.
The mode then recommended for its discovery and esti*
mation was, to extract from carefully dried blood serum, by
xxxvii. 4
50 BLOOD AND EFFUSED FLUIDS IN
means of hot alcohol, such matters as are soluble in that
menstruum; then taking up, by hot water, the urate of soda,
and after evaporation, either crystallising that salt, or by the
addition of a foreign acid, liberating the uric acid, and after-
wards collecting and weighing. This process requires con-
siderable time and care in the manipulation, especially if any
attempt be made at determining the quantity ; and hence,
although it is a method most desirable to have recourse to,
in investigating the pathology of disease, yet it is one which
cannot readily be employed in clinical medicine.
To obviate this difficulty, I have devised another mode of
ascertaining the presence of uric acid in the blood, which
I have been in the constant habit of using clinically
during the last four years, and with the results of which I
have every reason to be well satisfied ; it is a method which
can be readily employed by every medical practitioner, and
which has the advantage of requiring for its performance the
abstraction of only a very small amount of blood. I have
named the process the "Uric Acid Thread** experiment,
which is thus performed.
'* Take from one to two fluid drachms of the serum of
blood, and put it into a flattened glass dish or capsule ; those
which I prefer are about three inches in diameter, and about
one third of an inch deep, which can be readily procured at
any glass house ; to this is added the strong acetic acid of
the London Pharmacopoeia, in the proportion of about six
minims to each fluid drachm of the serum ; a few bubbles of
gas are generally evolved at first ; when the fluids are well
mixed, a very fine thread is introduced, consisting of from
one to three ultimate fibres^ from a piece of unwashed hucka-
back or other linen fabric, about one inch in length, which
should be depressed by means of a small rod, as a probe or
point of a pencil. The glass is then put aside in a mode-
rately warm place, until the serum is quite set and almost
dry; the mantelpiece in a room of the ordinary tem-
perature answers very well, the time varying from eighteen
to forty-eight hours, depending on the warmth and dryness
of the atmosphere.
GOUT^ BHEUMATISMj AND BRIGHT^S DISEASE. 51
'^ Should uric acid be present in the serum in quantities
above a certain small amount noticed below, it will crys-
tallise, and during its crystallisation will be attracted to the
thread, and assume a form not unlike that presented by
stone sugar upon a string (see fig. 1). To observe this
appearance, a linear magnifying power of about fifty or sixty,
procured with an inch object-glass and low eye-piece, or a
single lens of one sixth of an inch focus, answers perfectly.
The uric acid is found in the form of rhombs, the size of the
crystals varying with the rapidity with which the drying of
the serum has been effected.^'
To ensure perfect success, several precautions are necessary,
1. The glasses should be broad and flat, as above
described : watch-glasses of the ordinary kind are not good,
being too small, thus allowing the fluid to be frequently
spilt; and too much curved, causing the film of partially
dried serum to curl up and split.
2. The acetic acid should be neither very strong nor weak.
Glacial acid often forms a gelatinous compound with the
albumen of the serum, and the appearance of flakes ; and
very weak acid adds unnecessarily to the bulk of the fluid.
By experience I find the acidimi aceticum (Pharmacopoeia
liondinensis) to be well suited for the experiment.
3. The character of the thread and its quantity is of
some moment. Very smooth substances, as hairs or fine
wire, but imperfectly attract the crystals : if the number or
length of the fibres be too great, and the amount of uric
acid small, the crystals become much scattered, and there-
fore but few appear in the field of the microscope. The
glass should not be disturbed during the drying of the
serum, or the crystals become detached from the thread.
4. Some attention to temperature is necessary; if the
serum be evaporated at a high temperature, above 75° Fahr.
for example, the drying may take place too rapidly to allow
crystallisation ; the temperature of an ordinary sitting room
answers well for the purpose.
5. If the serum is allowed to dry too much before the
examination takes place, the surface becomes covered with a
52 BLOOD AND EFFUSED FLUIDS IN
white efflorescence consisting of phosphates (see fig. 2)^
which may obscnre the thread ; this can be removed by the
addition of a few drops of water before putting the glass
under the microscope; sometimes over-dryiug causes the
serous film to become cracked or fissured throughout, as
well as covered with the phosphatic efflorescence.
6. It is well, when practicable, to put up two or more
glasses with the same serum.
7. The blood should be recently drawn; that is, no
change or decomposition should have been allowed to take
place before the experiment is made; the reason for this
precaution will be spoken of below.
Delicacy of the above Test for Uric Acid. — The serum
of healthy blood, and that of blood from patients suffering
from most diseases, gives no indication of the presence of
uric acid by the " uric acid thread^* experiment ; and this
absence of very extreme delicacy is of itself a most valuable
quality, as only in blood containing an abnormal amount of
this principle, will the acid be indicated. In my first com-
munication, where the results of several quantitative deter-
minations of the amount of uric acid in the blood in gout
and albuminuria were given, it will be seen, that in 1000
grains of serum it varied usually from 0*045 to 0*175 grain;
these numbers were necessarily smaller than the quantities
which really existed, being those actually separated and
weighed; guided by these results, I have endeavoured to
ascertain the value of the '^ uric acid thread^' experiment by
the following series of observations. For this purpose I
have taken serum of blood from the healthy subject, in
which the most careful analysis could with difficulty show the
presence even of a trace of uric acid, and to this serum have
added the acid in the form of urate of soda in certain definite
proportions. After testing such serum in the manner above
detailed, the following results were arrived at:
1. Serum with the addition of uric acid in the f gave no indication of
proportion of 0*010 grain in 1000 grains l uric acid.
2. Serum, containing 0-020 grain in 1000 grains [ " ^uric acid^^ °^
GOUT, RHEUMATISM, AND BRIGHT^S DISEASE. 53
3. Serum, containiDg 0-0250 grain in 1000 grains [^^^^ ^ SJrer^^*^^^ ^"
4. „ „ 0*030 „ 1000 „ „ a few crystals.
5. „ „ O'O^O „ 1000 „ „ several crystals.
C „ moderate sprink-
6. „ „ 0-050 „ 1000 „ i ling of crystals
on thread.
thread pretty
7. „ „ 0060 „ 1000 „ ] freely covered
with crystals.
„ very numerous
8. „ „ 0-080 „ 1000 „ ] crystals on
thread.
„ abundance of cry-
9. „ „ 0-100 ,. 1000 ,. } stals, more than
» » ^ J.\f\J ,f O-VVV „
»
usually found
in serum.
thread complete-
ly covered with
10. „ „ 0-200 „ 1000 „ -! crystals of uric
" " " ^ acid, and nume-
rous scattered
crystals.
It appears, therefore, that an amount of uric acid equal to
0025 gr. in 1000 grains of serum, in addition to the trace
existing in healthy serum, is required to be present in the
blood before the ^' uric acid thread^* experiment gives indi-
cations of its presence, and hence the appearance of the
uric acid on the thread becomes complete evidence of an
abnormal or morbid quantity in that fluid.
Changes which Uric Acid undergoes in the Blood when removed
from the Body,
In enumerating the precautions which should be observed
in making the " uric acid thread^* experiment, it was stated
that recently drawn blood should be employed, and the
importance of this will be seen from the following obser-
vations, which at first perplexed me not a little. Having
ascertained the presence of uric acid in the blood in many
cases, and put aside the serum for a time, it was found
that on repeating the experiments, no indication of the
54 BLOOD AND EFFUSED FLUIDS IN
presence of that acid could be discovered ; this circumstance
more frequently happened in the summer months. On
closer examination I found that the serum had usually
undergone some slight decomposition, which gave me at
once a clue to the explanation of the phenomenon, namely,
that uric acid existing in blood is broken up, or undergoes a
species of fermentation, when the albuminous portion of the
serum becomes altered in character. In order to verify this,
the following experiment was repeatedly made, and with
uniform results. Uric acid in the form of urate of soda
was dissolved in serum in the proportion of from 010 gr.
to 0*30 gr. to 1000 grains of serum, and the fluid allowed to
become putrid. The whole of the acid was found to be
destroyed, no indications being afforded by the " uric acid
thread^* experiment, although at first abundance of crystals
were obtained.
I have made some few experiments in order to discover the
change which the uric acid undergoes under the above-
mentioned circumstances.
"When submitted to the action of certain oxidising agents,
as the puce-coloured or per-oxide of lead, it is broken up into
oxalic acid^ urea, and allantoin ; and when the oxide is in
excess, the oxalic acid is further oxidised and converted into
carbonic acid. This fact led me to try whether oxalic acid
might not be formed in the blood-serum from a change in the
uric acid, and for this purpose I made daily observations on
such serum during its decomposition, and found evidence of
the formation of oxalic acid in the occurrence of octohedral
crystals of oxalate of lime; after a time these crystals
appeared to become less numerous, and at last to vanish.
I have also evaporated the serum when decomposition was
taking place, and treated the residue in the manner described
in my paper on ' The occurrence of Oxalic Acid in the Blood,'
published in the 32d volume of the ^ Medico-Chirurgical
Transactions,' Many crystals of oxalate of lime were thus
obtained for the most part octohedra, some agglomerated
into oval bodies, some similar to dumb-bells. To make
the experiment more conclusive, I have taken serum
GOUT, RHEUMATISM, AND BRIGHT^S DISEASE. 65
of blood not containing an appreciable amount of uric acid,
divided into two parts, and to one portion have added urate
of soda in small amount, and allowed both quantities to de-
jcompose ; it was found that in the portion of serum to which
the urate had been added, oxalate of lime octohedra were
formed, but not in that portion free from uric acid. The
microscopic examinations were made with object-glasses
giving a linear magnifying power of from 200 to 400. Much
further investigation is required on this subject; enough,
however, has been done to show that the study of these
changes is not without interest to the pathologist, for there
can be little doubt that oxalic acid is formed in the animal
body, not, as formerly supposed, from the oxidation of
saccharine matters, but from the decomposition of uric acid.
Very many observations on the occurrence of oxalic acid in
the blood of man and the lower animals, since the publication
of the paper above referred to, have convinced me that such
is the case.
Non-occurrence of Uric Acid in the Perspiration of the
Gouty Subject.
There are several instances on record in which a whitish
powder has been noticed as occurring on the skin of gouty
patients, especially after profuse perspirations, and this has
not unfrequently been supposed to consist of some combi-
nation of uric acid, but no proof of the presence of this body
in the excretion from the skin has, I believe, ever been given.
In 1853, I adopted the following plan, in order to discover if
uric acid is thrown out by the skin of gouty patients. A
man was selected suffering from a severe attack of gout, who
had been subjected to the disease for a long time, who had
many tophi or concretions of urate of soda, and in whom the
blood gave, at the time, abundant evidence of containing a
large excess of uric acid. Several folds of white bibulous
paper were steeped in a very weak solution of potash, and
applied for about thirty hours to the abdomen, protected by
oil-silk. The papers wfere rendered acid, and were found to
56 BLOOD AND EFFUSED FLUIDS IN
be Strongly impregnated with the perspiration, and to con-
tain much organic matter ; these were treated with rectified
spirit, and afterwards with hot water, and the watery
solution, when evaporated, carefully examined for uric acid.
No trace of this body could be discovered, by the murexide
test, nor any crystals separated by the addition of acetic
acid.
When we consider that the excretion from the skin is
very acid in character, and very deficient in saline matters,
it would hardly be thought probable that a substance having
the properties of uric acid would be excreted with it, either in
the free state or that of a saline combination.
Discovery of Uric Acid in certain Morbid Effusions.
I am unacquainted with any published analyses which
have demonstrated the presence of uric acid in fluids effused
into cavities in disease; but as far back as the year 1848,
soon after my first communication to the society, I made
some investigations upon this subject, and found indis-
putable proof of its occurrence. The first of these were
made on the abdominal and pericardial fluids in a case of
granular kidney, with cirrhosis of the liver, and extensive
cardiac disease ; for some days prior to death, suppression of
urine had supervened.
Abdominal Fluid. — Golden yellow colour, rather thick
and turbid ; slightly acid in reaction at first, but becoming
alkaline on partial evaporation. Odour during evaporation
similar to the perspiration. Sp. gravity, 1013'54.
In 1000 parts were contained j ^^ J^ ; ; ; ^H^
100000
In the 36*40 parts of solids, there were 10- 79 parts of
albumen, and, on incineration, 6*94 parts of ash were left,
the salts consisting of phosphates, chlorides, and sulphates ;
evidence of uric acid was obtained, in its separation in the
GOUT, RHEUMATISM, AND BRIOHT^S DISEASE. 57
crystalline form, and also of urea; the weights of these
bodies, however, were not determined.
Pericardial Fluid. — This was lighter in colour than the
above, in other respects similar. Reaction acid, Sp.
gravity, 1010-60.
Trt^^ . r Solids . . . 24-53
1000 grams gave\ ^ . n^r^ .«
° ^ t Water . . 975-47
100000
The solids yielded, of —
Albumen 10-53
Salts (ash) 9*70
Uric Acid 0-069
Urea .... weight not determined.
Since the time the above analyses were made, I have as-
certained the existence of uric acid in effused fluids in
several cases where the blood gave evidence of containing
an abnormal amount of that principle. I have many times
crystallised it from such fluids by the '* uric acid thread^'
experiment.
Discovery of Uric Acid in the fluid artificially effused by the
application of Blistering Agents^ or in Blister- Serum,
Not unfrequently in practice, for the sake of diagnosis, it
is desirable to ascertain the condition of the blood, as to the
presence or absence of uric acid, in cases where, from the
state of the patient or other causes, the abstraction of that
fluid cannot well be effected, and it occurred to me that,
probably, the fluid effused by the application of a blister would
contain this acid, if the circulating fluid were impregnated
with it; experience has proved the truth of this conjecture.
The following are some of the results I have obtained by
the use of the " uric acid thread'^ experiment, which may
be employed for the discovery of uric acid in blister-serum
as well as in blood-serum :
58
BLOOD AND EFFUSKD FLUIDS IN
1853.
Feb. 9.
E. W.
March 5.
J. W.
(Serum of blood.
Sp. gr. 1029-2, at 46°
Falir.
Abundauce of uric
acid on thread.
'^Serum of blood.
Sp. gr. 1026-4, at 51»
Fahr.
Abundance of uric
acid.
{Serum of blood.
Abundance of uric
acid.
'^Serura of blood.
Sp. gr. 1029-6, at 47'
Fahr.
Abundance of uric
acid.
T? k n f Serum of blbter.
^^^^'t^^' -^Abundance of uric
I acid.
E.W.
March 6.
J. W.
{Serum of blister.
Abundance of uric
acid.
March 28. fSerum of blister.
— K I Sp. gr. 1022-8, at 46°
Attack pass-] Fahr.
ing off. (^Crystals of uric acid.
March 29.
J. H.
June 30.
C. S.
Nov. 8.
M.J.
I No
blood taken.
1854.
January 2. -
C.F.
rSerum of blood.
Sp. gr. 1026-8, at 62**
' Fahr.
Crystals of uric acid
not very numerous.
'"Serum of blood.
Sp. gr. 1026-8, at 50°
Fahr.
Abundance of uric
April 1.
J.H.
June 30.
C. S.
Nov. 11.
M. J.
Jan. 13.
C. P.
rSerum of blister.
Sp. gr. 1024-8, at 54°
^ Fahr.
Abundance of uric
acid.
rSerum of blister.
< Numerous crystals of
L uric acid.
Serum of blister.
Sp. gr. 1024-0, at 65°
Fahr. .
Crystals of uric acid
several in numlx^r.
rSerum of blister.
< Moderate amount of
L uric acid.
acid.
It appears^ then^ from these results^ that the fluid effused
by the action of a blistering agent applied to the skin, will
give evidence of the presence of uric acid when the blood
from the same patient exhibits the phenomena, and in the
performance of the experiment the same precautions must
be taken as have been before indicated when the process
with blood-serum was detailed ; but, in addition to these,
one more circumstance must be attended to, namely, that
the application of the blister should not be made to an
inflamed part, for it seems that the existence of inflamma-
tion^ has the power of preventing the appearance of
^ The inflammation attending the production of a blister does not appear
to destroy the uric acid.
GOUT, RHEUMATISM, AND BRIGHT^S DISEASE.
59
uric acid in the effused
results :
1854.
January 2.
C.i\,
patient be-"
fore referred
to.
serum, as shown by the subjoined
Serum of blood.
Abundance of
acid.
uric
January 2.
C. F.
ditto.
{Serum from blister on
inflamed (gouty)
dorsum of Land.
No trace of uric acid.
1853. rSerum of blood.
Dec. 21. < Abundance of
C. C. F. L acid.
1854. rSerum of blood.
Jan. 15. < Abundance of
F. P. l^ acid.
uric
uric
fSerum of blister from
Dec. 23. J inflamed (gouty)
C. C. F. 1 knee.
^No trace of uric acid.
{Serum from blister to
inflamed (gouty)
knee.
No trace of uric acid.
Should further inquiry confirm the result which the above
limited number of observations appear to point to, namely,
that during the existence of inflammation in a part, there is
a destruction of the uric acid (when such exists) in the
blood of that locality, and other independent researches
which I have made appear to favour much this idea, it may
hereafter throw no small amount of light on the pathology of
certain morbid conditions of the system; in the present
paper, however, I have abstained, as much as possible, from
connecting the condition of the blood with any specific dis-
ease, reserving that subject for my next communication on
" Gout and Rheumatism,^^ when their differential diagnosis,
and the nature of the so-called ^' rheumatic gout,^' will be
discussed.
With regard to artificially effused fluids, I may observe
that, during crystallisation, the uric acid usually assumes a
form slightly different from that in which it occurs in blood-
serum, the crystals having a greater tendency to become
agglutinated, and form irregular masses, as seen in fig. 3.
Lastly, these effused fluids may be employed, not only to
ascertain the existence of uric acid, but likewise of other
principles, as urea and sugar, which are contained and can
be detected in them, when, in the blood of the patient, their
presence is capable of demonstration.
ON
EXCISION OF THE KNEE-JOINT
BY
G, M. JONES, Esq., M.R.C.S.E.,
SURGEON TO THE JERSEY HOSPITAL.
Received April 10th.— Read April 11th, 1854.
Whether excision of the knee-joint be a justifiable
operation or the reverse, is a point which has been discussed
both at medical and surgical societies, and among prac-
titioners at large. There can be no doubt that there
exists an extensive prejudice against it, it being con-
demned by a large majority of British surgeons ; but few
of the later writers on practical surgery speak of it in a
manner to encourage its performance ; others are altogether
silent on the subject ; while in France, if thought of at all,
it is so only in connexion with the memory of the Moreaus.
This cannot fail to appear extraordinary to those who
have given the history of this operation the least attention,
for though it must be admitted that in several instances it
has terminated fatally, still, as the following facts will prove,
few attempts at curative surgery ever promised better at their
commencement than this did.
The first well authenticated case in this country (for
though Mr. Filkin^s, which occurred in 1762, is said to have
succeeded, it wants data to substantiate it) was performed
in 1781, the cure in this instance being perfect; "the patient
was afterwards able to perform all the duties of a seaman.^^
The operation was performed in France in 1792, and certainly
with success, for although the patient died three months
after of "epidemic dysentery, which, as is well known,
carried of£ the greater portion of those whom it attacked,'^
62 EXCISION OF
the operator, whose word is above suspicion, states, ^'I looked
upon my patient as cured, for I had no relapse to dread/^
Again, in 1823, it was twice performed in Dublin. It is
true that in the first case bony union did not take place, but
then " disease had proceeded too far ; in a word, the case
was one to which the operation of excision was not appli-
cable." The patient, however, lived more than three years,
in all probability quite as long as she would have done had
amputation been resorted to. The second case proved more
fortunate ; for three years after, the report says, "the patient
is able without assistance to stand or walk the length of the
day."
In Edinburgh, excision of the knee-joint was performed in
1829, the little patient recovered, so that Mr. Syme^ referring
afterwards to this case^ expresses himself as "having no
doubt that ultimately the excised limb will be nearly as
useful to him as the other." Mr. Syme repeated the
operation the following year, but unsuccessfully, the child
dying within the fortnight.
I have brought forward these cases not only as being the
first in England, France, Ireland, and Scotland, but also to
show that an operation which its present advocates are some-
times blamed for performing, was not considered an un-
surgical procedure in the hands of such distinguished men
as Park, Crampton, Moreau, and Syme, each of whom doubly
sanctioned it by its second performance. The result of these
cases certainly bears out my previous assertion, that few if any
attempts at curative surgery have ever promised better at
their commencement ; and I may also add that few have
ever so soon been allowed to fall into disuse, as from the
time of Mr. Filkin's operation until 1850, a period of eighty-
eight years, but twelve cases are on record.
In the year above named (1850) this operation was re-
newed by Mr. Fergusson, of King's College Hospital, and
no better proof can be oflfered of the estimation in which the
views of this surgeon are held, together with the determi-
nation of many practitioners of the present day to advance
conservative surgery to the utmost, than the fact;J;hat in the
THE KNEE-JOINT.
63
space of little more than three years no less than twenty-one
operations of excision of the knee-joint are recorded. The
subjoined table will show the result of all the cases I have
been able to collect, several of which have not yet been
published.
Excision of the Knee- Joint, from 1762 to 1854.
Date.
Aug. 23, 1 762
July 2, 1781
June 22, 1789
Sept. 17, 1792
, 1811
Oct. 21, 1809
, 1816
May 7, 1833
Aug. 4, 1823
Surgeon.
Mr. Filkin
Mr. Park
Mr. Park
M. Moreau
M. Moreau
M. Moreau
Mr. Mulder
Professor Rous
Sir P. Crampton
Sir P. Crampton
Name of Patient, Su;.
A man, name unknown
Hector M'Caghen, set.
33, a sailor
Chas. Harrison, set. 30,
a wheelwright
M. Claude, set. 20
A man, no name given
A man, no name given
A pregnant woman
A man, set. 32
Susan Connally, set. 25
Ann Lynch, set. 22
Result.
Case not well authenti-
cated. It is stated,
however (on the au
thority of Mr. F.'s
son), that on Nov. 21
of the same year, ** he
was got so well, as to
require no further
attention."
Cured. " Afterwards
performed the duties
of an ahle seaman."
Died, 115 days after the
operation, of exhaus-
tion.
Cured. For although
the patient died 3^
months after the ope-
ration, the surgeon
says, " I looked upon
my patient as cured,
for I had no relapse
to dread." The bones
had become consoli-
dated.
Died shortly after the
operation.
Cured.
Died of tetanus on the
110th day.
Died of phlebitis on the
18th dav.
Discharged from hos-
pital on 27th June,
1824, " in very good
health," but no bony
union had taken place
between the femur
and tibia. Died of
phthisis, three years
and two months after
the operation.
Cured.
64
EXCISION OF
Date.
Dec. 7, 1829
Dec. 28, 1830
July 20, 1850
Jan. 19, 1851
April 27» f,
Sept. 4| „
Jan. 25, 1852
May 5,
June 7,
Sept. 19
Oct. 30,
February 5,1853
March 16,
„ 28,
April 2,
♦»
1r
ti
It
>t
April 17,
Oct. 31,
Dec. 24,
if
ft
ft
tt
tt
Jan. 8, 1854
Feb. 15,
tt
Surgeon.
Mr. Syme
Mr. Syme
Mr. Fergusson
Mr^ Jones
Mr. Jones
Mr. Jones
Mr. Jones
Mr. Mackenzie
Mr. Page
Mr. Jones
Mr. Fergusson
Mr. Mackenzie
Mr. Pritchard
Mr. E. Thomas
Mr. Fergusson
Dr.Steward,BeL
fast
Mr. Jones
Mr. Gore, Bath
Dr. Keith, Aber<
deen
Mr. Butcher,
DubHn
Mr. Mackenzie
Mr. E. Thomas
Mr. Erichsen
Name of Patient, &c.
John Amot, set. 8
Ann Mackintosh
A man, let. 21
Sarah Hansford, set. 25
John Le Gros, set. 10
Miss Le Maistre, set. 30
Robert Quarm, let. 7
John Johnston, set. 28
Wm. Graham, set. 16
Ab. Le FeuTre, set. 19
Ann Goring, set. 20
Wm. Harrisson, set. 42
E. H., a man, set. 20
John Harrett, set. 12
Emma Saville, set. 28
No name or sex g^ven
Wm. Livermore, let. 12
A boy, set. 14
A boy, set. 9
Result.
Miles Christie, set. 17
John Christie, set. 16
Wm. Shaw, set. 7
Cured.
Died, eleven days after
operation.
Died on the ninth day
of acute necrosis of
the femur.
Cured.
Cured.
Died of epidemic dy-
sentery, fourteen days
after the operation.
Cured.
Cured.
Cured.
Cured.
Cured.
Cured.
Cured.
Cured.
Died of phlebitis, on the
sixteenth day.
Unable to obtain fur-
ther information than
"that the
encouraging
Cured.
Recovered.
Recovered.
Progressing favorably.
Died of exhaustion, the
twenty-second day.
Under treatment.
Under treatment
case
tt
was
The above table shows that six of the cases are my own,
and their being no longer under treatment, renders them, I
apprehend, fit subjects whereby to test the value of the
operation. Before proceeding further, however, I must
anticipate the very reasonable remark, that my inferences
are drawn more particularly from my own practice ; the only
excuse to be oflfered is, that previous to visiting the me-
tropolis in November last, I had never witnessed the operation
of excision, nor even seen a patient who had submitted to it ;
and, having been for nearly thirty years deprived of the
opportunity of being present when such interesting cases
appear, as draw forth the surgical talent of men from whose
THE KNEE-JOINT. 65
practice and remarks so much valuable information is derived,
I am forced in advocating excision of the knee-joint to fall
back on those cases which have come under my own care, and
thus to appear egotistical against my wish ; at the same time
I must confess my impression, that remarks from one who has
been completely thrown on his own resources, are of more
value in forwarding the cause on which so much interest has
of late been excited, than those of men who are without
practical experience.
The question may naturally be asked, why this operation
has been more successful in my hands than in those of
others? The reasons are obvious; consisting in the great
advantages arising from the locality and consequent salubrity
of the Jersey Hospital. It is not surrounded by high and
crowded buildings and a dense population, but has a large
piece of ground in front, and a garden at the back, both of
which are open to th^ patients for exercise ; and its left wing
is scarcely two hundred yards from the sea. The wards are
airy, and but rarely crowded; and I have hitherto made
it an invariable rule to have a separate, well-ventilated
room, as well as a special nurse or nurses, for each of the
patients on whom excision or any other important operation
is performed. These incalculable advantages are unattaina-
ble in metropolitan' hospitals, and to them alone, with the
stimulating treatment commenced immediately after the
operation, and steadily persevered in for a considerable time,
is my success to be attributed.
The objections raised against the operation are twofold.
Its severity, the shock to the system, danger from haemor-
rhage, erysipelas, burrowing sinuses, wasting suppuration,
fee, forming the first class ; and from these it is argued that
amputation is much less hazardous. Then, supposing the
patient to have overcome or escaped these dangers, we are
told that want of union in many cases renders the limb use-
less ; and if the subject be a child, the absence of growth in
the excised member is brought forward to prove that a
wooden leg, in all instances, is of much greater utility than
xxxvii. 5
66 EXCISION OF
the one on which excision has been practised. These once
formidable objections can now be combated by existing
proofs of their want of weight — ^the operation having been
frequently performed without endangering life further than
would have been the case in amputation ; and we can from
experience affirm that no mechanical contrivance yet known
can approach in utility to the limb which has been subjected
to this much condemned operation. My own experience
enables me fearlessly to assert, that in five of my cases no
greater constitutional derangement followed than I have
witnessed after the most favorable cases of amputation ; in
none has the haemorrhage been sufficient to require either
ligature or torsion; nor has the slight appearance of erysipe-
las, in one or two cases, justified even a mementos uneasiness.
It must be admitted that suppuration is greater after ex-
cision than it is even in stumps which heal by granulation,
in consequence of its longer continuance ; but it is, as far
as I have been able to judge, less weakening to the system,
being much more gradual, and consequently not so exhaust-
ing. The first class of objections thus do not appear to be
borne out by those cases which have fallen under my obser-
vation, and I cannot help believing that the two which were
seen last November, by many of the most eminent surgeons
in London, must prove satisfactorily that excision in those
cases claims a marked superiority over amputation. As re-
gards the remaining objections, I strongly suspect that the
case brought forward by Mr. Syme in support of his opinion,
will prove the exception rather than the rule.
Three of my patients were children, under ten when
operated on, and in neither of these has growth been stunted,
as is apparent from the fact, that the boxes in which the
excised limbs were confined immediately after the operation,
are now much too short to contain them. The following
forcible statement, forming part of the history of Mr. Pagers
case, with which that gentleman kindly favoured me some
time back, goes very far to prove the correctness of my
views on each point of the subject.
THE KNEE-JOINT. 67
"I saw the patient this day (January 25th, 1854); he is
quite well, the limb is firmly anchylosed and perfectly
straight. He has now for some time been employed at the
steam looms of a cotton factory, where he works as long as
the other hands — and he has to walk or stand the greater
part of the day. He walks well without inconvenience or
fatigue ; in proof of which, he informied me that on Sundays
he not unfrequently takes a walk of seven or eight miles.
I may mention the important fact, that the boy has grown
several inches since the operation, and that both legs happen
to have grown equally in length, there being now, as at first,
about three inches of diflference between them."
The same plan of operation has been followed in all my
cases, with the exception of the last : a lateral incision along
each side of the joint, and a transverse one immediately over
the centre of the patella ; the flaps then dissected upwards
and downwards, and the patella removed, the joint ends ex-
posed, and so much of the femur and tibia excised as was
found in a disorganised state ; the bones being then placed
in juxtaposition, and secured in a suitable box, similar in
some respects to Sir Astley Cooper^s fracture-box. This
method, as far as I have been able to learn, is the one
usually pursued. It had, however, some time before occurred
to me that this plan might be improved upon, and having
found such to be the case, I can now recommend the latter
plan as one possessing the greatest advantages.
It is somewhat remarkable that similar views should, at
the same time have been entertained by my friend, Mr. R.
J. Mackenzie, Surgeon to the Royal Infirmary, Edinburgh,
though I had not then the pleasture of his acquaintance,
even as a correspondent. He arrived in Jersey a few days
after my last operation had been performed, and on stating
to him the method adopted, I found that he had for some
time been impressed with its practicability, and probable
advantages, and had, moreover, decided to follow it out
substantially on the first opportunity, which he did shortly
after his return, there being this diflference between our
68 EXCISION OP
practice — Mr. Mackenzie preserved the patella, but divided
its ligament. The subjoined case ^ill show in what respects
our operations differ^ and also the superiority of this new
method over the old one, and will, I trust, induce the
greatest contemners of this operation to admit, that at all
events in one case, excision of the knee-joint has obtained a
triumph in its results which amputation could not possibly
have achieved.
My patient, a boy, set. 12, had for some time suflFered
under strumous affection of the right knee-joint, which had
in no way yielded to the treatment ordinarily pursued in
such cases, consequently the operation of excision was per-
formed on the 17th of April last, and in the following
manner : — A longitudinal incision, full four inches in extent,
was made each side of the knee-joint, midway between
the vasti and flexors of the leg ; these two cuts were down
to the bones, they were connected by a transverse one just
over the prominence of the tubercle of the tibia, care being
taken to avoid cutting by this incision the ligamentum patelUe;
the flap thus defined was reflected upwards, the patella and
its ligamentum were then freed, and drawn over the internal
condyle, and kept there by means of a broad, flat, and turned-
up spatula ; the joint was thus exposed, and after the syno-
vial capsule had been cut through as far as it could be seen,
the leg was forcibly flexed, the crucial ligaments almost
breaking in the act, only required a slight touch of the
knife to divide them completely; the articular surfaces of
the bones were now completely brought to view, and the
diseased portions removed by means of suitable saws, the
soft parts being kept aside by assistants. In this case the
external condyle of the femur was found hollowed out by a
large abscess, so that it was necessary to saw off (obliquely)
another portion of the carious bone, and to gouge out the
remainder, until healthy cancellous tissue was reached, the
articular surface of the patella had also to be gouged until
sound bone was attained; the bones were now brought in
apposition, and the patella and its ligament replaced as
THE KNEE-JOINT. 69
nearly as possible in their natural position, the remaining
parts of the operation, together with the after-treatment,
were conducted in the same manner as in my other
cases.
I shall not enter into details respecting the progress of
the case, it is sufficient to say that before the expiration of
seven weeks, the little patient was able to turn the limb
from side to side easily and quickly, and to raise the leg
from the hip upwards without assistance or appliance of any
kind; the patella then adhered firmly to the femur and
tibia, and its ligament preserved its integrity: unfortunately,
however, for some weeks before this gratifying termination
occurred, symptoms, which had never before manifested
themselves even in the slightest degree, supervened, excru-
ciating pain was felt in the opposite hip, which most ener-
getic measures for a time were unable to mitigate; after
many weeks^ suffering, the pain by degrees lessened, while
the limb became gradually shorter. A spontaneous luxa-
tion had taken place, so that at present my little patient
when walking, which he does with the assistance of only one
stick, presents the following anomalous appearance : on
the right foot he wears a thin shoe, and on the left a boot,
the heel of which is upwards of two inches thick; the exist-
ing lameness is only perceptible on the left side, and is not
apparent on the right, and the leg which, under ordinary
circumstances, ought to have had at first almost all, and
^ throughout life the proportionably greater part of, the onus,
would now be almost the useless member described by the
opponents to this operation, without the powerful and
almost entire support of the one on which excision has been
performed.
May not the question now be asked, if in this case am-
putation had been resorted to, could any patient with a
wooden leg on the right side, and a dislocated and diseased
hip on the left, be able to walk with no other assistance than
one small stick ? The answer is too obvious to be dwelt on
for a moment.
70 EXCISION OP
It is only by comparing cases that we arme at a right
conclusion respecting the superiority of one mode of ope-
rating over another; the preservation of the patella and
of its ligament is^ I feel satisfied^ a plan which ought to
supersede the other^ and be followed out in those cases in
which it is practicable; the operation thus performed is
rendered more tedious and difficulty but these are secondary
considerations when it results in obtaining a more favorable
issue.
The rectus acts as a splint^ and not only assists materially
in keeping the bone in apposition^ but also counteracts the
natural tendency of the limb to become bent; and I cannot
help believing that^ should union of the femur and tibia not
take place^ the preservation of the patella and its ligament
must render the limb more useful than it would otherwise be.
The following quotation from a paper written nearly fifty years
ago, by Dr. James Jeflfrey, of Glasgow, is so conclusive on
the point that I cannot resist giving it. In speaking of
Mr. Parkers and Moreau^s operation, this gentleman says —
" It may be said that, though it be an object of impor-
tance to preserve the attachment of the extensor muscles
in elbow cases, where the joints remain moveable, the
surgeon may consult his own convenience at the knee,
because that joint, after the operation, is stiff. But it
should be considered that, though the crureus and the
vasti be extensors of the legs, their auxiliary, the rectus
femoris is a flexor of the hip-joint also, and of course a
bringer forward of the thigh'; and to lose the use of that
muscle, in walking, &c., must always be a serious inconve-
nience, whether the knee-joint be stiff or not ; because it
acquires power by contraction, the length of the lever with
which it acts increasing as the muscle becomes shorter:
whereas, most of the other flexors of that joint lose power,
their lever decreasing in proportion to the decurtation they
suffer in acting. Except, therefore, it be supposed that the
ends of the common tendon of the extensor muscles, when
cut above the patella, or the ends of the ligament that con-
THE KNEE-JOINT. /I
nects the patella to the tibia, unite after the operation, it is
obvious that, by the transverse incision, the power of bringing
forward the limb must be impaired/^
But, while earnestly recommending the operation of ex-
cision as a valuable substitute for amputation, I would not
be understood to say, that it can be had recourse to in all
cases. In those which are commonly called white swelling
of the knee, among others, it may occasionally be quite in-
admissible, but in this, as in all other respects, I feel per-
suaded that the adhering to one mode of treatment, whatever
be the circumstances, must produce frequent disappointment;
the general features of the case must decide the course to be
adopted by the surgeon in this operation, as well as in any
other that may come under his notice. As in cases which
ultimately necessitate amputation, we are bound in the first
place, to exhaust all those means which, if resorted to in an
early stage, and judiciously persevered in, may not unfre-
quently effect a cure ; still one important fact must not be
lost sight of — the greater the debility of the system before
excision, the smaller are our chances of success, while the
larger amount of integrity in the soft parts will certainly
facilitate the cure. There are some few cases which, though
for a time regarded as hopeless, yet under constitutional
and local treatment, come to a happy termination; still
these cases, while they point out the necessity of due re-
flection before attempting an operation which may endanger
life, must not be too much relied on, and when it is found
that constitutional disturbance keeps pace with local symp-
toms, it appears to me to be consistent with sound surgical
principles, that the means of avoiding amputation be no
longer delayed ; and as in all cases in which excision is de-
cided on, we are, at the same time, prepared to amputate
should our diagnosis have proved incorrect, ought we also to
be prepared to abandon it altogether, if the admirable plan
advocated, and in some instances so successfully followed, by
Mr. Gay, that of making free incisions along the joint,
offers us the hope that by these means a cure may be
ON THE RADICAL CURE
OF
REDUCIBLE INGUINAL HERNIA,
BY
A NEW OPERATION,
WITH CASES AND REMARKS.
BY
T. SPENCER WELLS, F.R.C.S.
Received April 10th.— Read May 9th, 1864.
In the year 1847 I assisted Dr. Burmester at Malta to
perform an operation for the cure of reducible inguinal
hernia. The operation adopted has not been made known
in this country so far as I am aware. It was devised by
Professor Wiitzer, of Bonn, and I shall presently de-
scribe it.
Dr. Burmester's patient was a gentleman 28 years of age,
who had suflfered for about eight months from oblique
inguinal hernia on the right side. The external ring was
dilated, but the intestine had not descended into the scrotum.
The inguinal canal readily admitted an ordinary-sized finger.
The patient was strong and healthy. He objected very much
to wear a truss. No dangerous symptom followed the
operation. The patient remained in bed eight days, and was
confined to his room a fortnight longer. He afterwards wore
a truss for four mouths. It was then left off, and he had
not had any recurrence of the protrusion a few months ago
when I heard from him, upwards of six years after the
operation.
I have since performed this operation twice myself in two
very similar cases ; one in the year 1848, and the other in
1850. One patient was a naval oflficer, the other a groom,
7Q THE RADICAL CURE OF
their ages being 18 and 20, and the hernia of recent forma-
tion, both oblique inguinal on the right side. Complete
success followed, and although both patients are accustomed
to very active exercise, no return whatever of the hernia has
taken place.
I have not met with other cases suitable for operation in
my own practice; but when at Bonn in the year 1850,
Professor Wiitzer showed me two of his patients upon whom
he had performed the operation, one only eight days before I
saw him, the other about two years before. No unpleasant
symptom had followed in the first case, which was going on
well, and in the second a radical cure had been effected. In
reply to a question I lately addressed to the professor as to
the numerical results of his operations he says : " I am not
able at present to give you the statistical results of all the
cases upon which I have operated, as I have not time to col-
late them. I can now only say that, since the autumn of
1838, 1 have repeatedly practised my operation in the Klinik
every session before many witnesses, and that I have never
seen severe peritonitis follow it, still less any fatal result. All
those operated on have not been cured. In several relapse
followed, but this was traceable either to the patient's
leaving off the truss too soon, or undertaking very hard
bodily labour soon after the operation.^' When at Vienna
last year. Professor Sigmund informed me that he had per-
formed the same operation nineteen times in the great hos-
pital of that city, a successful result following in fifteen cases.
In two cases gangrene of the integuments followed, and in
two others relapse occurred after some weeks, but no death
had happened. Professor Rothmund, of Munich, has pub-
lished the result of his operations on the same plan in the
hospital of that capital. He had operated thirty-five times
in thirty-two cases, in two years and a half, and no death had
followed. His results are almost uniformly successful; but
I am informed by a gentleman who wrote to me lately from
Munich, that these statements are not deserving of very great
weight, as the patients were not watched long after the ope-
ration to test the occurrence of relapse. But I trust that a
REDUCIBLE INGUINAL HERNIA. 77
few remarks upon a method of operating which has led to
the results I have just recorded may not prove unacceptable
to the Society.
When a surgeon operates skilfully upon a strangulated
hernia at the proper moment^ he achieves one of the greatest
triumphs of our art, for he unquestionably saves the life of
the patient without removing or deforming any part of his
body. A surgeon who should invent a method of radically
curing hernia certainly and safely, would be a great public
benefactor, not only by relieving thousands from the incon-
venience of wearing a truss, but by averting the danger of
strangulation to which they are continually exposed to, in a
greater or less degree, through every period of life. It may
be said, that the security aflPorded by a well-fitted truss is
almost perfect, and the meonyenience it produces not very
great, but patients diflfer very much in their estimate of the
evils of wearing a truss for life; and the frequency with
which strangulation occurs among persons who do wear
trusses, proves that a more eflfectual safeguard is required.
Every one must admit that the balance of opinion in the
present day among the most experienced surgeons of Great
Britain, France, and Germany, is decidedly against any
operation for the radical cure of hernia. It must alsp be
admitted, that the opinion has been formed upon facts which
fully justify it, for the various modes of operating condemned
have been often followed either by death, dangerous peri-
tonitis, gangrene of the soft parts, or by recurrence of the
protrusion, so that the patient, after exposure to danger, has
been left in no better condition than before. So far as any
proceeding implies either opening of the hernial sac, its
destruction by the cautery or caustics of any kind, its scari-
fication, the introduction of foreign bodies into it, or the
application of a ligature around its neck, every man of sound
judgment must agree with the general opinion. For, even
if the danger of peritonitis or gangrene were escaped, one
would naturally expect that adhesions of the neck of the sac
would soon extend, become loose, and give way before the
pressure of the viscera, and a new hernial protrusion occur.
78 THE RADICAL CURE OF
But the question becomes quite a different one when a mild
operation of invagination, skilfully practised in properly
selected cases, has to be considered. It is true, that Gerdy's
method of invagination, although occasionally successful, has
led so often to death, or to gangrene of the scrotum and
exposure of the testicle, and in the more successful cases has
been so often followed by relapse, that it has fallen de-
servedly into discredit, and is now very seldom performed.
But if an array of facts, such as those I have collected at the
commencement of this paper, prove that invagination can be
so performed as to be safe and generally effectual, perhaps
the opinion now entertained may be modified.
The radical cure of reducible hernia can be effected in two
ways : 1, by inducing union of the two opposed serous sur-
faces of the hernial sac by adhesive inflammation and
exudation ; and 2, by producing close union with an organic
body pushed from without into the canal.
I think it better to pass over the various plans which have
been adopted with the hope of curing hernia by the first of
these plans ; for, with the exception of compression, they have
all been exploded. A well-fitted truss, properly and perma-
nently applied, gradually excites exudation and adhesion,
and in young persons hernia of very considerable size is fre-
quently cured radically without further treatment. But, in
adults, compression is only palliative ; for the cases in which
it effects a radical cure are so rare, that such a happy result
is scarcely to be expected in any given case.
The attempts of Belmas,Gerdy,Leroy-d'Etiolles, Signoroni,
and Jobert, to close the hernial canal by means of organic
union with it of a part of the body of the patient himself,
though sometimes successful, have on the whole proved that
it is desirable to adopt some plan by which the same end
might be attained more safely and securely. It being
understood that the inguinal canal must be closed by a
portion of skin pushed into it, the first precaution necessary
is to effect the closure in such a manner that the adhesive
inflammation which it is desired to excite in the hernial sac
should not extend to the peritoneal cavity.
BEDUCIBLE INGUINAL HERNIA. 79
Now it has been supposed by Gerdy and others that, when
a hernial tumour is pushed before the skin of the scrotum
by the finger of the surgeon, the sac is pushed upwards ;
and that the needle, passed after the method of Gerdy, does
not implicate the sac. This, however, is not the case. It
is contrary to the anatomical condition of the parts. The
serous hernial sac is so firmly adherent to the inner surface
of the inguinal canal, that it cannot be separated without the
assistance of the knife. In one case recorded by Wiitzer,
where a hernia had only existed three days, the adhesion of
the sac to surrounding parts by inflammation and exudation
was so firm, that separation could only be eflfected by the
knife. If the sac were really moveable, the attempts of
Gerdy and every other surgeon to cure reducible hernia radi-
cally would necessarily be uncertain, for all we have to trust
to is closure of the abnormally dilated canal by adhesive
inflammation. We must consider all this fairly in judging
of any operation. Professor Wiitzer did so before he devised
the instrument which is now brought before the Society.
He thought that the most safe and promising plan of closing
the canal would be by effecting upon its whole inner surface
up to the internal ring (and when possible closing the
ring itself) an equal mechanical pressure which could at
any time be increased or diminished as might be desired or
requisite. While keeping a compressing instrument firmly
fixed during several days, all use of the knife, and of every
caustic under whatever name, should be excluded, and
the entrance of air into the peritoneal cavity carefully
prevented.
80 THE RADICAL CURE OF
It may be seen that the instrument consists first of a
cylinder of very hard wood. This is 8J inches long, and is
made of different diameters, according to the breadth of the
canal. It is destined to take the place of the index finger,
after the latter has pushed a part of the scrotum through
the abdominal ring into the inguinal canal. Towards its
anterior blunt extremity it becomes gradually thinner. It
contains a canal, lined with metal, which conducts an elastic
steel needle, flattened on the point and furnished with a
moveable handle. A round opening near the point of the
cylinder allows the needle to pass through, so that, when the
cylinder has been properly introduced, pressure upon the
handle of the needle sends its point along the interior of the
cylinder, the skin of the scrotum, the serous coat and cover-
ings of the hernial sac, projecting at last through the inte-
guments. In order to increase the pressure which the
wooden body remaining in the canal itself exercises, a move-
able case of hard wood is made concave, corresponding to
the outer convex side of the cylinder. It is made rather
wider than the cylinder, projecting two or three lines on
either side, in order to distribute the pressure more equally,
and near the end is an opening to receive the projecting
point of the needle, which thus fixes one end of the cover
over the cylinder. The other end is supported upon a
moveable metallic staff; near this is a screw, by means of
which cover and cylinder can be pressed together to any
degree of strength, so that in a moment the anterior wall
of the hernial sac, of the inguinal canal, and the tissues
between the cylinder and the cover can be compressed to
the precise degree each case may require.
The cylinders are made of various calibres, to adapt them
to the different diameters of the inguinal canal, as a great
deal depends on the proper filling of the canal by the
cylinder, the pressure of which should operate as equally as
possible upon all parts of the inner surface of the sac. On
the other hand, the diameter of the cylinder must not be
too great, or it would be impossible to pass this blunt end
to the internal ring, and our object would be defeated; a
REDUCIBLE INGUINAL HERNIA. 81
diameter of five to seven lines suits such cases. The in-
vagmated scrotum fills the rest of the canal.
The instrument is used in the following manner : — After
the hair has been shaved ofiP^ the bladder and rectum
emptied^ the patient lies on his back, with the thighs flexed
and raised, and the operator stands or sits between them.
The intestine is replaced, if down. The surgeon then places
the point of his left forefinger upon the scrotum, about an
inch below the abdominal ring, on the affected side, and by
carrying the finger, with its palmar surface directed upwards
and outwards, through the ring into the canal, he pushes
the yielding skin of the scrotum into the canal as deep as
practicable ; at all events, so far that the apex of the cone
of skin thus formed reaches the internal ring. The cylinder
having been oiled, it is now introduced by the right hand,
withdrawing the finger as the instrument enters. This is
not always done without diflficulty, and requires some prac-
tice : the invaginated skin may return as the finger is with-
drawn, and require replacement; or, in cases where the
ring is moderately narrow, the cylinder may not be easily
introduced by the side of the finger. In this case the finger
must be partially withdrawn, to make room for the advance
of the end of the instrument. Again, in old hernise the
cellular tissue about the ring is so lax, that the cylinder
may be pushed up beneath the skin outside the canal ; when
this happens, the cylinder is found, on examination, to be
much more moveable than when it is within the canal.
When convinced that the cylinder properly fills the inguinal
canal, the needle is passed through the cylinder, the canal,
and the integuments ; the wooden cover-plate is placed over
it, and pressed against the skin by the screw ; the handle of
the needle is then unscrewed, and the projecting point ia
covered by a small piece of cork.
The patient is kept quiet on his back, with the knees
bent and supported by pillows. The diet must be so regu-
lated that, on the one hand, we may not prevent a suflBcient
degree of inflammation in the canal ; and, on the other, we
may guard against the further extension of it to the perito-»
XXXVII. 6
82 THE RADICAL CURE OF
neeum. Should symptoms of peritonitis occur^ they must be
immediately met with energy ; but this is very seldom the
case if the patient remain quiet. Very gentle pressure
should be employed at first ; but the screw may be tightened
daily, although, in doing this, it is advisable to raise the
plate, in order to judge of the degree of existing inflamma-
tion, and regulate the after proceedings by it. If this is
found to be more than requisite, the pressure is diminished,
or the instrument entirely removed.
About the fourth or fifth day the punctured wound begins
to suppurate, and there is more or less redness and swelling
around it. Professor Wiitzer says it is not necessary, on
the average, to leave it applied more than six days ; I have
left it seven and eight days. It should be withdrawn as
soon as serous fluid, containing fat and epidermis, begins to
ooze from the plug ; if left longer, injurious suppurative in-
flammation comes on, and gangrene may commence around
the needle puncture. When the instrument is removed,
the cavity which remains is filled with soft dry charpie,
the puncture is dressed simply, and the whole is supported
by a bandage. The patient should remain on his sofa, not
only until the cicatrisation of the puncture, but at least
eight days longer, so that the fresh adhesions be not broken
up by too early movements. In my second case I did not
follow Wiitzer's plan of introducing lint into the cavity, but
followed the advice of Rothmund, and endeavoured to pro-
cure union of the opposed surfaces of the plug by a graduated
compress. No union, however, took place. After either
plan, a firm plug is formed in the interior of the inguinal
canal, and at first an opening or depression is seen in its
mouth; but this entirely disappears after some months,
although the plug remains in its place. After a lapse of
years, the plug itself becomes gradually diminished, and can
scarcely be perceived on examination.
In order to ensure permanent success, the patient should
wear a suspensory bandage and a lightly-pressing truss for
at least three months after cicatrisation of the puncture;
otherwise the adhesions, while fresh and yielding, would be
REDUCIBLE INGUINAL HERNIA. 83
apt to give way, and the weight of the testicles, if not sup-
ported, might tend to draw down the skin of the scrotum to
its original position. Powerful exercise of the body should
also be forbidden until the truss can be left off.
Two important questions now suggest themselves : 1st. Is
the evidence adduced in favour of this operation sufficient
ground for admitting it within the province of legitimate
surgery ? and 2d. If so, in what class of cases should it be
performed ?
In answer to the first question, I can only refer to the
imperfect account of its results with which I commenced
this paper. Of 67 cases there reported, no death or dan«
gerous symptom followed in any one, and the proportional
success is large. Professor Wiitzer does not give the number
of cases he has treated, but we may presume that it is con-
siderable, and no death has resulted. I have heard that in
one case at Brussels death did follow, but that the operation
was very unskilfully performed, upon a patient suffering at
the time from primary syphilis ; so that this misfortune is
not to be attributed to the operation, but to the operator.
I think, therefore, that if any means are to be resorted to in
ordes to cure hernia radically, that Professor Wiitzer^s
operation is that which is the safest hitherto adopted, and
the one which offers the greatest chances of success. A
truss is always inconvenient : it never gives perfect security
against strangulation ; it excites in many persons, especially
during the first year or two of wearing it, a great deal of
mental annoyance, reminding them of a defect in the neigh-
bourhood of the genital organs ; it diminishes the aptitude
of the wearer for hard bodily labour or active exercise, for
there is no truss which can be trusted to keep up a hernia
in those who are employed to carry heavy loads, in seamen
who have to do duty aloft, or in grooms ; yet, as a rule, no
warning suffices to keep men from such pursuits because
they are ruptured. The cares of a family dependent on
labour for support, habit which has grown up from
early youth, and ignorance of the dangerous nature of the
hernia, are all reasons against an alteration in fixed modes
84 THE RADICAL CURB OF
of life. If all this be taken into consideration^ I think that
the danger attendant upon such an operation as that I have
described^ when carefully performed^ in fit cases, is slight,
when compared with the disadvantages to which a hernial
patient is exposed who has to wear a truss for the remainder
of life ; and therefore that we are bound not to neglect this
operation.
As to the class of cases in which it is indicated, perhaps
we might say — 1st. In all strong, otherwise healthy persons,
up to 40 or 45 years of age, who lead a life of active bodily
exercise. In such patients where the hernia has only
acquired a moderate size, has not become adherent, and
where the long diameter of the inguinal canal has not been
much shortened by the continued pressure of the intestine,
we can most certainly depend upon the excitement of a
passive exudative inflammation with subsequent adhesion —
in other words, upon a radical cure.
The inguinal canal becomes wider, and at the same time
shorter and narrower, the more extensive, old, and neglected
the hernia may be. At length the shortness of the canal,
the relaxation of its walls, and the large circumference of
both rings, form so many impediments to a succassful
union; and the attempt at a radical cure will be more
unsafe in proportion as these impediments increase. All
this must be taken into account when considering the
second class of cases in which this operation may become
advisable, namely, in patients who have not arrived at the
age of decrepitude, whose hernial tumours cannot be longer
kept up by any mechanical assistance. This may be the
case when the inguinal canal is extremely dilated and
shortened ; in certain species of omental hernia ; in cases of
great sensibility of the spermatic chord; and in persons
with a fat, pendulous abdomen, upon whom the pad of the
truss slips when they move. Such persons live in constant
danger of strangulation ; and in them herniotomy would be
infinitely more dangerous than invagination, performed at a
proper time. If the neglect have been carried to its highest
degree, and the rings have become widely dilated, probably
REDUCIBLE INGUINAL HERNIA. ^5
no method of operation will avail to close them perfectly ;
yet the patient gains a great deal if, by such a proceeding,
the evil can be at least so much diminished that a truss can
be successfully worn. In one such case, operated on by
Professor Rothmund, in an old woman who had a labial
hernia which had reached the knee, four fingers together
could be passed through the ring, and no truss was of any
use; yet, although no radical cure was eflfected by the
operation, it had the good effect that the hernia could be
afterwards properly kept up by a truss.
Allow me to add, in conclusion, that whatever operation
be proposed for the radical cure of hernia, it can only be
successful when the whole inguinal canal can be so perma-
nently closed by a new, firm, organic substance introduced
into it, that, besides the spermatic chord or round ligament,
no other parts can find their way through. All methods of
cure which can only stop the passage through the abdo-
minal ring must fail in their object, so long as any part of
the inguinal canal is left open. In successful cases they
may prevent the passage of an inguinal hernia into the
scrotum, but are incapable of obstructing renewed pro-
trusion of intestine into the inguinal canal — in other words,
of preventing a relapse of the hernia. It is in this respect
that Professor Wiitzer^s operation appears to me to be so far
superior to others, that I have ventured to bring it before
the notice of this Society. It will be for the members to
consider how far the evidence I have adduced of its safety
and success should lead to its further adoption in this
country.
OBSERVATIONS OF MORBID CHANGES
IN THE
MUCOUS MEMBRANE OF THE STOMACH.
BY
DR. HANFIELD JONES.
COMMUNICATBD BT
DR. BENCE JONES.
Received April 10th.~Ilead May 2H 1854.
It is not at all necessary for the object of this paper to
give any detailed description of the structure of the mucous
membrane of the stomach. It will be sufficient to refer to
the works of Todd and Bowman^ and Kolliker, and to state
that my own observations are quite corroborative of the ac-
counts they have given. On two or three points^ however^
a few remarks may be made.
I am inclined to agree with KoUiker that, in the normal
condition, there are no glands in the pyloric region of the
conglomerate kind or resembling a bunch of grapes, Bruch
has stated that he has seen such, and so have I in many
cases ; but I believe the appearance to depend on a morbid
change, in which partial destruction of some tubes takes
place, while their remains become convoluted and massed
together with adjacent tubes. The low villous prominences
which are almost constant in the pyloric region, and occa-
sionally exist in the middle, contain a quantity of nucleated
granulous substance, identical with that which is seen in the
villi of the intestine. This is liable to abnormal increase, and
then spreads as an interstitial formation downward among
the tubes. The existence of this nucleated substance beneath
88 MORBID CHANGES IN THE
the basement membrane of the intestine (large and small)
has not been su£Giciently noticed; it must be one of the first
seats of morbid change in inflammation^ and we have seen
bacony matter deposited in it. When I commenced my
inquiries into the morbid conditions of the stomachy I was
not aware that '' lenticular/' or solitary glands had been
seen in the mucous membrane. Dr. Todd and Mr. Bowman
make no mention of them in this situation; Kolliker
says^ ''the lenticular glands certainly do not occur con-
stantly in the stomachs of adults^ even if they are possibly
always present in those of children^ at least in very many
cases one meets no trace of them. In others they are
seen to be extremely numerous^ covering the whole surface
of the stomachy yet one can hardly forbid the thought that
the diseased conditions of the part^ which are always present^
have much to do with their formation.'^ From not imagining
that they could be normal structures, I termed them simply
'' nuclear deposits/' supposing that they were of new forma-
tion* This is, however, in all probability, not generally true,
or rather it is true only in a restricted measure. In some
animals the solitary glands exist in a very, marked manner.
If the mucous membrane of a pig's stomach be dissected off,
and macerated in dilute muriatic acid, the whole splenic
region will show a prodigious number of dead white, round
or oval, bodies, the size of a pin's head or a little larger,
lying on the deep surface of the mucous membrane, in which
they are partly imbedded. These consist of masses of
nuclei, with a very little granular matter. In the stomach
of the cat they may easily be displayed in the same way,
but are much swollen, and lie more completely in the sub-
stance of the mucous membrane ; they are not confined to
the splenic, but are seen in the middle and pyloric regions
also. In a rabbit's stomach I could find no trace of solitary
glands. In the stomach of a child, set. 5, who died of a
severe burn in a few hours, and whose organs appeared to
be all healthy, the glands in question were very nume-
rous. After dissecting off the mucous coat from the mus-
cular, and holding it up before the light, there were seen all
MUCOUS MEMBRANE OF THE STOMACH. 89
over the surface a great number of minute translucent spots^
about the size of a pin^s head^ in which the mucous membrane
appeared to be deficient, but was not apparently depressed.
When the mucous membrane was placed in dilute hydro-
chloric acid, or in tolerably strong acetic, the translucent spots
were changed, so as to present a dead whitish opacity. They
were most numerous and large in the pyloric region, and
were most apparent on the deep surface; in the splenic
region they were more numerous than in the mid, and were
quite distinct on the inner surface. They consisted almost
entirely of masses of aggregated nuclei. In vertical sections
these glands were seen lying at the bases of the tubes, and
often extending upwards a good way into the substance of
the mucous membrane. In a female, set. 23, single, dying
with scrofulous disease and abscess of one ovary, in an
extreme state of emaciation, the stomach was found tole-
rably healthy. On examining the mucous surface, in the
iiray above described, the same translucent spots were ob-
served, in which the tubes were absent, while their place
was occupied by nuclei and granular matter. In another
female, set. 19, dying of disease of the brain, set up by mis-
chief in the ear, the stomach, except some mammillation in
the mid and pyloric regions, was healthy. In the splenic
region there were a great number of minute pin-hole depres-
sions, well seen on looking at the surface by direct light,
and appearing as translucent spots with transmitted light.
Acetic acid rendered some of these opaque; dilute hydro-
chloric acid scarcely altered them at all. By microscopic
examination it was evident that the tubes were absent in the
situation of the spots, which were, in fact, minute cavities
containing a few nuclear particles and some oily matter. In
the first of these three cases (the child) I think the solitary
glands were in some degree abnormally developed. I have
not met with them so readily in the stomachs of other
children of about the same age. The second case shows
the condition in which, I believe, they usually exist in the
healthy adult. The third presents them so atrophied as to
'<»use a manifest loss of substance in the wall of the stomach.
90 MORBID CHANGES IN THE
It is difficult to fix any exact limit to the healthy deyelop*
ment of these glands ; all I can say is^ that I should regard
the gastric tissue as in its most normal and efficient state
when there were but few of these glands (or nuclear masses)
to be met with^ and when those that existed did not
encroach materially upon the tubes. It is probable that
there are great individual varieties, that they are naturally
larger and more numerous in some persons than in others.
The idea occurs very forcibly to the mind that these solitary
glands, and their groups in the intestine (Foyer's patches),
have really no use, and fulfil no function in the human
body, but exist in a rudimentary state, in obedience to the
law of unity of tjrpe. They may almost be regarded as
portions of undeveloped embryo substance, existing in inverse
ratio to the surrounding specially organised tissues, and with
this view their simple nuclear structure, the same that is so
common in embryonic parts, is very accordant.
It is, I think^ very nearly certain that the epithelial con-
tents of the tubes are thrown off during digestion^ and form
an important constituent of the gastric juice, probably the
so-called pepsin. The evidence for this view is the follow-
ing : — In some instances the epithelial contents of the tubes
do not extend up to the surface, i. e,, do not occupy the
fossulse; while in others they are seen fused into an uniform
mass, with remarkably definite outline which protrudes from
the fossulse on the surface, and resembles very much a villus
or papilla. In one specimen I observed, in a vertical section^
a layer of matter, apparently exuded epithelium, covering
the surface, which was continuous beneath, with columns of
epithelial substance rising out of the fossulse. Dr. Beaumont
seems to have noticed these papilliform protrusions of epi-
thelium in the living organ, as he mentions that, on
'* applying aliment, or other irritants, to the internal coat of
the stomach, and observing the effect through a magnifying
glass, innumerable lucid points, and very fine nervous or
vascular papillse, can be seen arising from the villous mem-
brane, and protruding through the mucous coat, from which
distils a pure, limpid, colourless, slightly viscid fluid.'' The
MUCOUS MEMBRANE OF THE STOMACH. 91
substance of which these papilloid masses are made up is
much more homogeneous than the epithelium of the tubes^
neither cells nor nuclei can be easily seen in it. The epi-
thelial particles seem to fuse together as they are thrown off.
This may serve as an answer to the objection which
KoUiker seems to adduce, viz., that the proper cells of the
tubes are not to be found at all constantly in the layqr of
mucus lining the surface. That this is the case I am quite
convinced, for, on examining the stomach of a cat killed
while digestion was going on, I found, on examining the
layer of chyme in immediate contact with the surface, no
trace whatever of any cell structure at all, neither of
columnar nor spheroidal epithelium. In vertical sections
of the mucous membrane there were, however, seen some
masses of altered epithelium within the fossulse, and ready
to exude. On the other had, in the stomach of a man who
died suddenly after a meal, I found the layer of acid mucus
in contact with the surface to consist of abundance of epi*
thelium from the tubes, as well as flakes of columnar
particles. Also, in vertical sections, examined without any
pressure, the surface was seen to be encrusted with a layer
consisting of distinct cells from the tubes. The proceeding
which Lehmann successfully adopted in the preparation of an
artificial gastric juice, viz., scraping the surface of the
mucous membrane with a spatula, and using the expressed
matter, indicates pretty clearly that the contents of the tubes
are poured out in the formation of the natural secretion.
Probably the only difference between different individuals
consists in this, that in some the epithelium liquefies
completely before it exudes, while in others it exudes as
a mass and liquifies more gradually. Though KoUiker
doubts that the exuding of the epithelium is a constant and
necessary occurrence in digestion, yet he holds that the epi-
thelial contents are all necessary for the formation of gastric
juice. I can corroborate the statement of this excellent
anatomist, that the acid reaction is much more intense in
that part of the stomach where (in the pig) the gastric
glandular structure is most developed. This corresponds.
92 MORBID CHAN0E8 IN THE
aUo^ with the observation of Messrs. Todd and Bowman^
p. 206^ vol. 11^ as to the greater digestive powers of the mid
region of the pig^s stomach.
The following observation relative to the condition of the
gastric mucous tissue at birth^ seems worth recording. The
stomach of a male infant^ who lived only four hours^ con-
tained much mucus^ of a reddish tint^ and markedly acid.
In the splenic region the tubes were not distinguishable in
vertical sections; they were utterly overlaid and obscured
by interstitial nucleated tissue. In the mid region the
tubes were rather more distinct ; there were numerous large
cells of tubular epithelium seen, but the tubes themselves
were very much obscured by interstitial nucleated tissue.
Acetic acid brought the nuclei into view in great numbers.
In the pyloric region the tubes were quite distinct^ though
there were here also numerous elongated interstitial nuclei.
The blood in some of the injected capillaries of the villi was
changed into yellow {figment (by the secreted acid). In
this instance we have another illustration of the often ob-
served fact, that the embryonic condition resembles very
much certain diseased states of adult life. The tissue at a
certain part of the ascending scale of development is very
like, in its mere morphetic characters, to the same tissue
when descending the scale of degeneration.
In the tables accompanying this communication, the fol-
lowing deviations from the typically healthy condition are
mentioned :
1. Nuclear masses ; these, as I have stated, are the soli-
tary glands, and it is doubtful what degree of their develop-
ment is to be considered as surpassing the physiological
limit. It seems probable, both from actual observation, and
from the behaviour of the same structures in the intestines,
that they may become hypertrophied, and encroach abnor-
mally upon the proper secreting tissue. Again, it is certain
that they may undergo atrophy, and thus occasion loss of
substance and thinning of the mucous membrane in the
spots they occupy. Sometimes their atrophy seems to take
MUCOUS MEMBRANK OF THE STOMACH. 93
place by a kind of liquefying^ so that a cavity is formed
containing a clear fluid and some nuclear corpuscles. In
other instances there is no distinct cavity^ though there may
be a depression on the mucous surface^ and the mass appears
to degenerate fattily^ the wasting corpuscles being mingled
with molecular oily matter, often in large proportion. Prom
the large, probably hypertrophied masses, there is a gradual
transition to the next form of change. It seems worth
while to retain the term " nuclear masses,^^ as it expresses
correctly the constitution of the so called solitary glands,
and, it being clearly understood that they are not actually
abnormal structures, separates them in a marked manner
from the proper secreting tissue.
2. Diffused nuclear formation, in extreme instances, extend
uniformly throughout the mucous membrane. The nuclei
are mingled with more or less granular matter, and the
tubes are more or less atrophied and obscured by the inter-
stitial deposit.
3. Inter-Mular fibroid formation, this is very commonly
associated with the preceding, and consists simply in this,
that the exudation in which the nuclei lie^ passes into the
form of a more or less fibroid or homogeneo-flbroid stroma.
In this, elongated or fibre-forming nuclei may sometimes be
seen. The material is very similar to that which thickens
the Glissonian sheaths in some cases of cirrhosis. In some
cases a change takes place in the tubes themselves, such
that they become converted into nucleated substance, similar
to that which surrounds them. Their epithelial contents
are changed into a granular mass, containing many more
nuclei than in the healthy state, while the homogeneous
wall of the tube wastes and disappears, and so the intra-
tubular nucleated mass blends with the extra-tubular, and
the whole mucous membrane is converted into an uniform
material loaded with nuclei. In extreme cases the tubes
are utterly atrophied, and the whole thickness of the mucous
membrane is occupied by fibroid or granular stuff, in which
some altered remnants of the tubes may be brought into
view by means of acetic acid. The basement membrane of
94 MOBBID CHANGES IN THE
the surface is often absent in parts where there is muck
inter-tubular formation^ and the nucleated fibroid tissue is
then exposed. It may, however^ have been covered in by
the columnar epithelium during life.
4. The tubes appear^ in some instances, to decay spon^
taneously, or, at least, not from the atrophic pressure of new
formed fibroid tissue ; the mucous membrane may then pre-
sent a mere mass of granular and celloid debris, with inter-
spersed fat vesicles and fatty matter.
5. Black pigment may be deposited in the mucous tissue
sometimes in great quantity; it is occasionally within the
tubesy more often between them. It appears in the form of
granules and masses. In other cases yellow pigment is to
be found. Both are to be regarded as proceeding from
altered hsematine.
6. Cystic formation is occasionally met with ; it seems to
take place in three ways : (1.) A nuclear mass liquefies, and
leaves a cavity which is occupied by a clear fluid. (2.) While
atrophy of the tubes is taking place, a portion of one becomes
distended into a cystic cavity. (3.) A cyst is produced
{de novo) as a large vesicle, a true new formation,
7. MammUlation is often seen in lesser degrees, and not
unfrequently well marked. It afiects especially the pyloric
third or half of the stomach. To obtain a good view of it,
or indeed not to overlook it, it may be absolutely necessary
to wipe off a thickish layer of tenacious adhering mucus. It
seems to be of two kinds, or to be produced in two ways.
One may be called healthy, and appears to depend on some
unusual contraction of the corium of the mucous membrane.
That this may take place is very intelligible firom the cir-
cumstance stated by Middeldorpf, and confirmed by KoUiker
and Briicke, that there exist numerous organic muscular
fibres in this layer. I have observed that this mammillated
appearance is produced in some specimens in a very marked
manner, or, if not entirely produced, rendered much more
striking by immersing the mucous membrane in water, or in
dilute acid, which seems to have a constringing action on
some of the component tissues, probably the corium. The
MUCOUS MEMBRANE OF THE STOMACH. 95
other form of mammillation is morbid^ and seems to be
essentially connected with fissuring of the mucous membrane^
or local atrophy. The thickness of the mucous layer is
tolerably uniform in the healthy state^ but in some cases
when it is dissected off and held up to the lights it is seen
to be much thinner in certain parts than elsewhere. The
glandular layer seems to be^ as it were^ broken up into
separate portions by fissures running through it. This
condition may exist without any mammillation. A section
made at right angles to the surface across a depression
between two mammillae shows the tubes in that part
shortened^ sometimes at the free surface only, some-
times at the deep also. The cause of the shortening seems
to be in many instances the disintegration of a super-
ficially seated nuclear deposit. The notching or depression
thus produced is sometimes so deep as to fissure the mucous
membrane quite down to its corium. In some cases the
notching may be the result of simple atrophy, or superficial
ulcerations, or such cracks as occur in psoriaris of the
skin. The following case is a good example of atrophic
change taking place extensively with partial conservation of
the healthy structure : — A man, aet. 57, died from a frac-
ture of the skull. The surface in the splenic region at its
lower part presented numerous spots about the size of a pea,
much more prominent than the intervening surface, and
when held up to the light these spots were seen to be much
less translucent than the intervals. These prominent spots
were more numerous and closer together in the lower part
of the mid-region, at the upper part of which, and in the
pyloric, there was marked mammillation. The tubes were
found to persist, and to be healthy in the prominent parts,
while in the intervening thinner they were very much
atrophied amid an overwhelming infiltration of nuclei, with
circumscribed nuclear deposits at the bases of the tubes. It
seems pretty clear that there is a good deal of analogy
between morbid mammillation, the result of organic change,
and the granular condition of a wasted kidney. The mam-
millations and the granulations are the parts where most of
the natural tissue remains.
96 MORBID CHANGES IN THE
8. Gathering up of the lower parts of the tvhes in the pyloric
region so as to form a group, of convolutions something like
the acini of a conglomerate gland is often observed. It is
not quite clear how the change is produced. It seems as if
several tubes lost their upper parts by obliteration^ and that
their then remaining portions were drawn together and
convoluted. In an extreme instance the groups of convolu^
tions are found lying beneath the mucous surface^ surrounded
by fibrous tissue, and manifestly destitute of any outlets. In
these cases the epithelial contents of the tubes are commonly
fatty and wasted.
9. There is much difficulty in determining exactly what
conditions of the epithelium of the tubes are unhealthy. Their
contents are often of a very opaque fatty aspect, especially
in their lower half; but this scarcely seems to be abnormaL
* In a few instances I have observed an apparently true fatty
degeneration of the epithelium^ the nuclei and cells being
converted into shrunken fatty masses. Not unfrequently
the epithelium appears more or less stunted and atrophied^
or of a less soft, finely mottled aspect, and its cells look
withered and shrunk. In the catarrhal condition it is pretty
certain that it is not only the epithelium of the surface and
fossulse (the columnar), which furnishes the abundant mucus,
but that of the tubes also, which is thus diverted from its
proper use. Large cells from the tubes may not uncommonly
be seen imbedded in the tenacious plasma. Sights however^
is quite inadequate to detect the qualitative changes which
the epithelium in these and other cases undergo.
10. Self digestion, in slighter degrees, is of very common
occurrence, and is invariably confined to or most marked in
the splenic region. The mucous membrane is stained more
or less deeply of a reddish colour, is less thinned, very slippery,
difficult to hold so as to make a section, and semi-transhicent.
The tubes appear in some measure wasted, the submucous
white filamentous tissue partly dissolved, and the blood in
the vessels converted into yellow pigment. In much rarer
cases the mucous membrane is destroyed, all except a
slight coating that still remains along some of the vascular
MUCOUS MEMBRANE OF THE STOMACH. 97
ramifications which are seen coursing as black streaks on the
white submucous tissue. The nerves and vessels are seen
altered just as when they are treated with strong acetic acid;
their nuclei are rendered very apparent.
11. Small dark red circumscribed spots seen on the
surface of the mucous membrane are manifestly the result of
hemorrhage, or at least of the exudation of hsematine. The
microscope shows in these parts an abundance of dark pig-
ment granules. Sometimes in these spots ulceration is
manifestly taking place ; the surface is sunk, the basement
membrane gone, the tubes quite lost, and replaced by a
fibroid tissue infiltrated with yellow pigment. With regard
to larger ulcers, such as perforate the walls of the stomach,
I have not been able to observe anything to distinguish
them from other ulcers, or anything that could account for
their origin and progress. The base of the ulcer has ap-
peared of a yellowish-grayish aspect, and some of the
substance forming it has shown nothing but a low fibroid
tissue, with more or less numerous corpuscles and granular
matter, in which lie imbedded fat-cells and remains of
vessels. In one instance there were numerous mould
filaments in the base of a gastric ulcer, and in another
instance in that of a duodenal ulcer ; but I do not at all
suppose that these had any essential connexion with the
lesions. The tissues bordering the ulcer have not presented
anything constant or to be specially noticed ; sometimes they
appear tolerably healthy, sometimes they are diseased in the
same way as other distant parts, sometimes they are the
seat of blood congestion, but this is not often the case.
Ulceration, I believe, is essentially dependent on that which
we cannot see; viz., a certain quality of the exudation, and
a certain alteration of the nutrition of the tissue affected.
It may, I think, be pretty safely asserted that examination
of an extending ulcer of the cornea would show no pecu-
liarity that could account for the progressive decay, and
absorption of the texture. When separation is taking place,
both the aided and unaided eye can see something of the
process that is going on, but the destructive action is only
xxxvii. 7
98 MORBID CHANGES IN THE
apparent by its results. When we understand the nature of
the assimilative power^ we shall understand also that of the
ulcerative. The following highly interesting case, for which
I am indebted to Dr. Bristowe, seems to me to have some
bearing on the mode in which ulceration occurs :
"A girl, set. 12, died at a late period of typhoid fever, from
copious intestinal hemorrhage. She was extremely ema-
ciated. There was hepatization and purulent infiltration of
a large portion of the left lung. The lower part of the
ileum presented numerous ulcers. But the most extensive
destruction of mucous membrane existed in the colon,
especially in the caecum and ascending portion. From this
part hemorrhage had taken place. The mucous membrane
of the stomach had a peculiar appearance. It presented a
very considerable number of depressions of a roundish, oval,
polygonal, or very irregular shape, the area of which varied
between that of a silver penny, and a quarter of that size.
They appeared to be produced by atrophy of the mucous and
submucous tissues. They were generally somewhat paler
than the surrounding healthy membrane, and many were
studded with black points, apparently discoloured vessels.
The black spots, though most numerous in the depressions,
were by no means confined to them. The morbid appear-
ance was observed over nearly the whole stomach, but was
deficient for an inch or two near the pylorus, and was perhaps
most distinct between the cardiac and pyloric extremities.
Not far from the pylorus was an irregular depression of the
largest size, having all the characters above described, except
that in its centre was a small oval darker-coloured pit in
which the mucous membrane appeared to be deficient. It
had the appearance of a contracting and imperfectly healed
superficial ulcer, and the thinner mucous membrane round
it was thrown into delicate scarcely visible folds/' In the
specimen which Dr. Bristowe kindly sent me the general
surface was pale, the margins of the spots were rounded over
smoothly, and not sharp cut. The spots were manifestly
depressed, and the tissue was more translucent in them than
elsewhere. On examination of vertical sections, the tubes
MUCOUS MEMBRANE OF THE STOMACH. 99
of the mucous membrane were found perfectly healthy; but
in the depressions they were destroyed, their place was
occupied by mere granular debris and oily matter, and the
basement line of the surface was lost. There was no par-
ticular change in the submucous tissue. The healthy tubular
tissue passed rather abruptly into the disintegrating, and
there was no deposit or morbid formation of any kind in
the parts affected. It was true and simple disintegration
and perishing. No injected vessels were seen by the mi-
croscope, nor any pigmentary deposits as from exuded
hsematine. The morbid condition in this case was the result,
I believe, of extremely depressed organic power. The
nutrition of the gastric mucous membrane, in particular
spots, failed, and the tissue passed into a state of decay^ it
might almost be said, of sloughing. This was not identical
with ulceration, but it verged nearly upon it, and had life
been prolonged, would doubtless have passed into it ; indeed,
in the large depression near the pylorus, ulceration seemed
actually to have occurred. The case may be regarded as a
transitional instance between sloughing and ulceration, and
illustrates both processes. Inflammation, it seems certain,
had nothing to do with it.
12. The mucus which covers the surface of the stomach in
gastric catarrh is generally very tenacious, adheres with
remarkable pertinacity to the membrane, is neutral or slightly
acid, and consists of an homogeneous-granulous fluid, im-
bedding very numerous columnar epithelial particles, and
often more or less distinct remains of the contents of the
tubes. The nuclei of the cells from the tubes persist long
after the cells themselves are quite disintegrated, and may be
seen in great numbers amid the plasma. They must not be
mistaken for mucous corpuscles, which I believe are very
rarely present. The columnar particles are more permanent
than those from the tubes. Small fragmentary crystals of
triple phosphate (as I believe them to be, from their solubility
in acid) are very commonly seen in abnormal gastric mucus.
The contents of the stomach are often of a dirty chocolate
colour ; in this case the fluid may be acid or alkaline : it
100 MORBID CHANGES IN THE
consists of watery mucous fluids containing besides epithelial
debris and remnants of food, numerous meshes of dark orange
pigment : these I suppose to result from eflfused blood or
exuded hsematine, and to be only a less degree of the black
matter which is often vomited in cancerous disease. I have
observed torulse in the mucus of the stomach of a diabetic
patient.
The tables accompanying this paper have been drawn up
from examination of 100 cases taken just as they presented
themselves. This way of proceeding is of course less ad-
vantageous for ascertaining the symptoms that attend on
diseased states ; but it gives, on the other hand, a fairer view
of the comparative frequency with which such states occur,
and seems on the whole the best to pursue in breaking
ground upon a subject which is in a great measure new. I
am too well aware of the extreme liability to error which
besets all statistical inquiries, to bring forward with anything
like implicit confidence the results which seem deducible
from these tables ; I only produce this as a first efibrt for
the ascertaining of points which will require further and
more diversified and abler observation to settle completely.
The proportion of males among the 100 cases is very far
above that of females, being 65 : 35, or nearly double. This
must be borne in mind in estimating the relative liability of
the two sexes to diseases of the stomach.
I will first examine the influence of age and sex. It
appears that out of the 100 cases, there were 28 that might
be considered quite healthy, or nearly so. Of these, 15
were males, and 13 females, which indicates a decided less
tendency to disease in the female sex.
There
were
10 under 10 years
of age.
13
»
20
»
16
j>
30
a
19
a
40
>»
23
a
60
»
The others ranged from 57 to 74. This result indicates
sufficiently a tendency to maintenance of the healthy state
MUC0X7S MEMBRANE OF THE STOMACH. 101
in the early years of life, and also demonstrates that organic
change is no necessary attendant upon old age. In case 33
there were numerous sarcinse in the stomach, and symptoms
of their presence were observed during life. In case 43
there was the most extreme vascular congestion, which how-
ever appeared to be more of a passive than of an active kind,
and to be produced chiefly in consequence of great fluidity
of the blood, and venous engorgement. In case 62, though
the glandular structure was generally healthy; there was an
ulcer with thin edges, at whose base a vessel was seen
nearly exposed ; the mucous surface was also in a state of
catarrh.
In 47 cases the splenic and mid regions of the stomach
were either healthy, or not greatly diseased, while the
pyloric was generally more or less afiected. In a few of
these the pyloric was as healthy, or more so, than the
other regions, but in the great majority the reverse was the
case. Of this group, 29 were males and 18 females, a ratio
not very dissimilar to that which exists between the numbers
of the sexes. This would indicate that the female sex is
as liable as the male to minor degrees of disease. Of this
series of cases, —
were under 10 years of age
5 «
20
14
30
22
40
33
50
40 „
60
While 7 ranged from 62 to 77.
Here, again, age appears to exert a decided predisposing in-
fluence to organic change. In 2 cases (53 and 67) there
were sarcinse in the stomach ; the latter was in a state of
catarrh.
In 11 cases there was a moderate amount of des-
truction of the tubes. Of these 10 were males, 1 female,
an excess on the side of the male sex which must be purely
accidental, at least in the degree indicated by the numbers.
„ were
»
2SU
11
)»
»>
30
»»
'»»
»»
40
11
a
II
60
II
102 MORBID CHANGES IN THE
1 of these was under the age of 10 years.
2
S
5
10
In 2 cases (Nos. 49 and 68) there were ulcers. In this
group it is very apparent how the liability to disease increases
with advancing age.
In 14 cases there was a great amount of destruction
of tubes. Among these there were 11 males and 3
females. This result coincides with that obtained in the
preceding group respecting the greater immunity of the
female sex from organic change of the stomach. The
numbers, however, are not sufficiently large to make the
evidence conclusive. Of these 14 cases there were —
under the
lage
of 20 years.
3 „
30 „
4
40 „
5
50 „
8
60 „
2
70 „
One was 70, and one was 90. Here again the influence of
advancing years is sufficiently apparent. In one of this
group, No. 40, there was cancer of the pylorus.
Among the 100 cases were 6 of more or less decided
ulceration, which are reckoned also in other classes with
respect to the general state of the mucous membrane. It is
rather remarkable that among these none were under 48
years of age. A case of perforating ulcer, which I met with
after I had completed the above number, was 52 years of age.
Including this one, there are seven cases, the average of
whose ages is 59. This was to me an unexpected result, as I
had believed, from the authority of others and my own
previous observation, that ulceration occurred chiefly in
young females. Of the seven cases, five were males, and
two females. Bokitansky states "that the disease occurs
chiefly at the period of puberty, and very often, particularly
MUCOUS MEMBRANE OF THE STOMACH. 103
in the female sex, as early as the tenth year/' He further
states "that it is invariably accompanied by chronic catarrh
and blennorrhoea of the gastric mucous membrane ;'' but
this I think is hardly the case in England. I have not
noted the existence of catarrh in more than three cases out of
the seven, and in one of these it is doubtful whether it was
at all marked.
In 16 of the 100 cases, the catarrhal condition was observed,
the surface being covered with abnormal mucus in greater
or less amount. Of these 10 were males and 6 females.
There were 2 under 20 years of age ;
5 „ 30
7 „ 40
9 „ 50
10 „ 60
And 4 varying from 64 to 11.
The frequency of catarrh thus increases with advancing age ;
but the earlier periods of life are by no means exempt.
There were 9 cases in which the patients were known
to have drank immoderately, and to these 2 more, sub-
sequently observed, may be added. Of these 11, 1 was
healthy; 6 were tolerably healthy, or not diseased in any
great degree; in 1 there was a moderate amount of de-
struction of the tubes ; and in 3 this was very great. From
this it would appear that the habit of hard drinking has not
a very marked effect in inducing degenerative disease of the
glandular structure of the stomach. The last case I examined
especially bears out this conclusion. The man was only 49
years of age ; he had been, as reported, '' a drunkard and a
very hard liver,^^ in the East Indies, had sunk himself
materially yi the social scale by his misconduct, and died at
last within a hospital mainly from debility. Except con-
siderable hypertrophy of the heart, and a fatty state of the
liver, there was no very decided organic disease. The mucous
membrane of the stomach was much congested, except in the
pyloric region. The splenic and mid regions presented a
very tolerably healthy state of their tubular structure. In
104 MORBID CHANGES IN THE
the pyloric region the tubes were atrophied and obscured by
interstitial nucleated fibroid formation. Just such a condition
this was observed in numerous patients whose lives had cer-
tainly been very unlike his.
Among the 100, there were 18 cases of marked scrofulous
disease, not including instances of tubercular deposit, which
were but slight, or obsolete. In 4 of them the gastric
structures were healthy. In 10 they were tolerably healthy.
In 2 there was moderate, and in 2 there was great de- *
struction of the tubes. The conclusion is that scrofulous
disease, using the term in its widest sense, does not exert
any marked influence in the production of organic disease of
the gastric gland tissue.
Without reference to microscopic examination, which, had
it been possible, would have been most desirable, there are
found among the 100 cases, 16 of renal degeneration occur-
ring without marked disease of the liver, and 8 in which both
organs were diseased. In the former group there were 3 in
which the gland tissue of the stomach was healthy (1, however,
of these was in a catarrhal condition, and had an ulcer) ; 5 were
tolerably healthy, 1 being affected with catarrh. In 2 there
was moderate destruction of the tubes, 1 of these presented
two ulcers and a cicatrix. In 6 there was great destruction of
tissue, but 1 of them had attained the advanced age of 90.
Of the second group of 8, — 1 was healthy, 3 were tolera-
bly healthy, in 3 there was great destruction of the secreting
tubes, and in 1 only moderate.
Taking the two groups together, it appears that in one
half the whole number there was decided organic change,
while the remainder were tolerably healthy, except that one
was ulcerated. This result points certainly, I think, to the
existence of a tendency in renal degeneration to be associated
with similar change in the stomach. That age is not the
real cause of the degeneration in the diseased cases appears
from taking the average of the ages in the two sets ; in the
healthy it is 52, in the diseased 51,
There were 12 cases of heart disease, chiefly dilated hyper-
trophy. 5 of these coincided with renal and hepatic degene-
MUCOUS MEMBRANE OF THE STOMACH. 105
ration^ 1 with renal degeneration only. Of the 12, — 4 were
healthy, 3 tolerably healthy, in 2 there was moderate de-
struction, and in 3 there was great destruction -of the
stomach-tubes. In 1 case of moderate destruction there
were also two ulcers and a cicatrix. The stomach disease
coincided with renal and hepatic (one or both) four times, once
it did not. From this it appears that heart disease, with its
usual attendant of venous engorgement, has probably no
great influence in the causation of degeneration of the gland
tissue of the stomach. In case 43, where the whole vascular
system of the stomach was intensely congested, the tubes
appeared tolerably natural.
Among the 100 there are found 7 cases of cancer, and to
these may be added 2 more subsequently observed. Of
these, 1 was healthy, 5 tolerably healthy, and in 3 there was
great destruction of the tubes. In 2 of these cases the
pyloric region of the stomach was itself the seat of the can-
cerous disease. The record of the healthy or degenerated
state relates of course to the condition of the remaining
mucous membrane. As the greater number of the cases
were tolerably healthy (as far as regards the stomach), as in
one of the diseased there was coincident degeneration of the
liver and kidneys, and as the average of the ages of the dis-
eased is considerably above that of the healthy (59 : 40), it
cannot be affirmed that cancerous disease has much potency
in inducing degeneration of the gland tissue of the stomach.
In only 3 cases out of the 100 is there mention made of
the patient's having sufiered from chronic rheumatism or
gout. In all of them there existed also renal degeneration,
and it is not possible to say whether this or that was the
cause of the great destruction of gland tissue which prevailed
in 2 of the 3 cases.
There are 2 cases of diabetes, in both which the gastric
tissue was tolerably healthy.
1 am inclined to hope that the appended tables will fur-
nish a good deal of illustration of diseased states of the
stomach, which can scarcely be embodied in formal deduction.
To aid the reader in his survev, I add references to the cases
106 MORBID GUANOES IN THE
which seem most worth his notice. Instances of great de-
struction of the secreting tubes : Nos. 2, 5, 8, 19, 29, 40,
44, 59, 63, 69, 76, 90, 92, 93. Instances of ulceration!
Nos. 6, 7, 49, 62, 68, 80. Instances of the catarrhal state :
Nos. 11, 24, 27, 34, 45, 48, 54, 57, 62, 67, 72, 74, 11, 80,
93, 99. Instances in which scrofulous disease was well
marked : Nos. 11, 16, 26, 34, 37, 39, 46, 47, 54, 57, 61, 63,
66, 79, 90, 91, 95, 100. Instances in which renal or renal
and hepatic disease existed : Nos. 3, 13, 19, 20, 22, 27, 29,
32, 35, 40, 43, 49, 62, 63, 69, 74, 76, 83, 84, 87, 90, 92, 93,
94. Instances of diabetes : Nos. 14, 79. Instances where
cancer existed : Nos. 5, 7, 15, 28, 40, 61, 11. Instances in
which the patients had been addicted to drinking : Nos. 3, 4,
5, 19, 26, 68, 80, 82, 93.
With regard to the symptoms by which these morbid states
might be expected to declare themselves, it has been matter
of great disappointment to me to find that they are so ob-
scure as to be scarcely at all noticed in the records to which
1 have had access. The following case shows that considera-
ble wasting of the glandular tissue of the stomach may take
place without any apparent symptom.
E. G., female, married, aet. 52, had been subject for eight
years to epileptic fits, occurring very frequently. In one of
these she set her clothes on fire, and was burnt severely.
She lingered for rather more than a month, and died. She
always had good digestion, never complained of pain in
stomach, could eat any kind of meat. Was very strong and
well nourished. All the organs appeared healthy except the
stomach, on the surface of which were several ecchymosed
spots, and the ileum and caecum, in which were patches of
deep red congestion. Microscopic examination showed the
tubes in the splenic region tolerably healthy; those in the
mid- region were utterly atrophied, and replaced by a fibro-
homogeneous stroma, densely loaded with nuclei and granu-
lar matter; those in the pyloric region were also extremely
wasted, and lost amid fibroid formation.
It is possible that in this case the part of the mucous
membrane which retained its healthy structure was able bv
MUCOUS MEMBRANE OF THE STOMACH. 107
increased activity to compensate for that which had perished^
and to supply an adequate amount of gastric juice. It
is^ however^ remarkable that so considerable change should
have occurred without any local symptoms. This probably
depended on the atrophic process having been very gradual.
Similar instances of latent^ though most serious changes^ are
met with in other parts — as the cardiac valves, the liver, and
kidneys ; so that the circumstance is by no means without
parallels. In the above case, and in others of the same kind
recorded in the tables, I believe the change to have been
quite independent of inflammation ; but in the following case
(for which I am indebted to the kindness of Mr. Aiicell),
attacks of inflammation seem to have been the efficient cause
of the morbid state.
A man died about the age of 50, in a state of atrophy and
exhaustion. He had suffered for years from dyspepsia and
congestion of the liver. The earlier attacks were of an acute
character, and were relieved by blisters ; the later were of a
more chronic kind. He was several times slightly jaundiced,
and his skin at last assumed a permanent dingy, greenish-
yellow hue. He was much troubled with sickness. Gentle
alterative treatment was of much benefit in the earlier
periods of his disease, but latterly nothing did him any good.
The autopsy showed some diminution in size of the liver,
whose cells were much loaded with yellow pigment; there
was some thickening of the capsule. The bile was exceed-
ingly yellow, rather abundant. The kidneys were large,
very highly congested, and their capsules very adherent;
their tubes contained fibrinous casts, and the epithelium was
unhealthy, containing a great deal of oil. Small concretions
of carbonate of lime were impacted in the mammellse. The
mucous surface of the stomach was marbled and mottled
over about its middle ; towards the cul-de-sac it was the seat
of punctiform injection if not of extravasation of blood. In
the part which was microscopically examined, there was very
little trace of the tubular structure, the tissue was completely
pervaded by nuclear deposit.
I am satisfied that this stomach was extensively aftected
108 MORBID CHANGES IN THE
by atrophy of its proper tissue^ with interstitial nuclear
formation^ although^ as I had not then directed my attention
specially to morbid conditions of this organ^ the examination
was not so satisfactory as those which I have made recently.
By a reference to the groups of different cases given above, it
will be seen that the catarrhal state is by no means coinci-
dent with destruction of the tubes either in its greater or
lesser degree. Now the catarrhal state implies a degree of
inflammation of the mucous membrane, but this does not
seem to have any marked influence in producing the
interstitial deposit which coincides with atrophy of the
secreting- structure.
In concluding this paper, which I feel is but a first
labour in a hitherto little cultivated field, I cannot but
remark how strongly the degenerative tendency charac-
terises the disease of the present day. We know not whether
it was so in former times, but for ourselves the lesson is
plain and clear, that the integrity of the vital force, which
we call health, must be carefully cherished if it is to be long
preserved. From diminished vital power there is no great
step to organic decay; and if the one exists any length of
time, there is too much reason to fear that the other is in
progress. If the researches I have made do nothing more,
they show that degenerative change in one important organ
is no unfrequent event, and it requires but a moderate
pathological experience to show that the same is true with
respect to many other parts. How does it then behove us
to look out for and anticipate, as far as possible, these insi-
dious disorganising processes, against which our therapeutic
endeavours are often so unavailing !
It is a pleasant duty to acknowledge the very kind assist-
ance I have received while engaged in collecting the
observations above recorded from the medical staff of St.
George's Hospital, and from my colleagues at St. Mary^s.
To the curators of the museums at both these institutions I
have to offer ray best thanks for the many friendly offices
they have done me, as well as to Mr. Philliten and Mr.
Mushen, resident officers at the Marylebone Infirmary.
HUCOCS MKMBa«NE
OF THE STOMACH.
109
1
1
1
11 i
■a
li
It
n
1
1
i
f
H
t
illil
111":
jimm
Jiiif
!iij
n
III
111
111
111*
ifii
m
.111.
m
mi
il
m
s
1
III 3 weeks or more vrithi B
fever; improved; ahewasap-'tions
petite was goods dovs before:
death, which occurred in an
=fit
li!
1 iiii
=1111
1
Nuraery gardener. Has
lived and drank bard at times
Rheumatic fever 10 years ago
Died of fever with pneumonia
plained latterly of pain and
nothing passed there.
Ills
ills
"Sis
1
^
s
S
^
9
i
1
1
2
1
H
i
«
«
S:
MOBBID CHANOBS IN THE >
ljM.ii'lt-|.i.i III! ... =
lllinirMplipilj l|:l
il!«liill|5:i1|l|J0l^l^
^i lllliiltfll l'ilHllltilJ
-lull's a43«| I ||s|"1b^-.
111
lis-sllll
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■a-S2"3sii
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s
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1
MUCOUa MEMBRANE OF THE STOMACH. Ill
iMiHiilfilPiilillii *i
«l||"i:3i-asH§||-E-c|;i|-^'2°5a^'3
ill 1^ ill ijliHIfi |i
HORBID CHANOES IN THE
1
.1
1
li
si
£ a
1
If
^.!|iflfp
tion of mucus acid. Mucous mem-
Riuch injected in splenic region, and
d generally with tenacious whitish
Splenic and mid region— tubes
c; much epithelium exuding on sur-
Pyloric region-tubes healthy, but
1
\
1
1
1
^■
1
3
111
i
ilil
si..-
isi
llFfllllilll
mils
1
1
ii
Body in good condition. Brain
and thoracic viscera healthy. Two
ulcerated openings at the uppei
part of the bladder were filled up
ly the intestines. Peritouitii and
jumlent exudation. Mucous hning
of bladder very congested, and of
an olive green hue.
111
.. "Ill
lis
1
i
1
Had good health until 9
months ago ; since then diffi-
culty in making water. On
admission, retention of urine
for 24 hours. Urine drawn
off excessively offensive, alka-
hue, turbid, loaded with triple
phosphates and muco-pus.
Appetite good. Urine became
almost black, opaque, and in-
tolerably fetid. He died in
a comatose slate, having pra-
riously had some pain in abdo-
men, the bladder being empty
Cough 1 year. Admitte.l
with muco-purulent, and
bloody expectoration. Legs
p
i-i
li
i
%
S
S!
i
t
s
S
1
p
i
«
^
2
=
2
MUCOUS MEMBRANE OF THK STOMACH. 113
«.•■?".»■ s Itasi.Bjs s-S'l.. SI'S!
^g' »|-l.ll|§| *25|sti ^■|s5fl"|i.|
111 Kllillii -iti1|1s =^s g"^!
lIlPiM liilii^ lillil j r 11 ^iii
4; -111 sit|.:| ■=■=
■|.Ha|3Q is ?*i &S ^ IS * § E!
houbid changes in thk
£„=SS1-|.^3 353^ siS-^-BEl SS.31I
ls|Jlt|ll.?|i5i t|s|l-!l t|l1l
Iji lif|i.r^?|!l ll a§-| "llif
= ^pill llfill =1lfif3| Tfil
5|iJ. fJll
'Is 1.1 "III
llii!!i"MI|l|l
i
J.
i
if
Reaction acid. Splenic region— there
was a good deal of sub-tubular nuclear de.
posit, which in one specimen was so con. X
aiderable that it formed a layer nearly as 3
on which it had encroached. Mid region- «
tubes healihy ; slight fibroid formation en-
croaching on their bases. Pyloric region — S
tubes remarkably healthy, and unobscured. S
Mocoas membrane appeared healihy, ^
rather more pinky than natural. Splenic re. -n
formation at their bases. Mid region-tubes a
very much obscured by fibroid deposit and "
much wasted, bat obscared a good deal by g
line perfect in all the regions. Very tittle >
sub.mucous tissue.
IE
mendis.
fibrinous
tion had
on of the
; one of
ntestinal
revcnted
Abdo.
lings eon.
parts of
softened
1
art very
itral eur-
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Aortic
rface of
ered by
a. Kid-
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nutmeg,
d; lower
y OiiB of
■?"£l 5*° ■■3.2 =■-
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■1l!lii| li!i!liiiillfltj
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" S-^ OB'S g-c -= £ s _ = rf " g-* I'-a e:s
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31
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liftiliillH
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I ^ i 3 1 1 ^--s = 1 1§ ^ ^ I S ^ 5 s -^ ^3 1 -^ - .= I J £-^
MUCOUS MEMBRANE OF THE STOMACH.
~ ° -s a -« "■
11 1^41
^ ^x-^1,% ■- J a -u I "S "
;-b55
■ "ill^i. •
„„.S8g«>Sa ^g'-ggg-a
UOKBID CBANOEB IN THE
lit g«|:i3i|l °« * ^ ! eli| lijifi! I
a-f.-|f?Si,E" , .Sj_'S^
|.|l|allt;5l^
;*ii
MEMBRANE OF THB STOMACH. 119
11
e S fl ^^.g
5 "B p -
ISslllt l-iKt
II I III "^Sgll^l
III
JjiPSi ^ilii?!iiJiiS5iii
= ^5lilil|,|ii^|i'l:ilp^i,i||l||
Fiif"'?ttff|ff5|ll|f!tjtii|
■!lf!!4 f|:l!}tl! ilUSliltli!i
SI
MORBID CHANGES IN TBR
1
Reaction acid. MammilUtion of mid and
pyloric regions. Splenic region contained
head. No marked injection anywhere.
Splenic region— lubes lolerably healthy,
but the continuity of their line was often
or by wasting of the tubes on their free or
their deep ends. There were nuclear de.
posits in the sub-tubular tissue and in the
muoouB membrane. Mid region— tissue in
nearly the same state ; a cyst was seen in one
nuclear deposit at the free surface. Pyloric
region — tubes much obscured by fibroid
rormition. The mid and pyloric regions
were covered with yellowish green mucus.
Mucous surface injected much; mammil-
aled ; lined with bloody mucus ; not acid.
Hid region- tubes tolerably healthy;
)Iack pigment in the topi of the short villi ;
a cyst seen lying near Ihe surface. Pyloric
reg'ion- tubes much obscured; not wasted.
II mid-region ; it consisted chiefly of finely-
granulous matter, free nuclei, and small
cell ptitidet.
1
1
i
1
liary tubercles in longs. Bron-
tcrofuloua deposit in it, and in
Intestines vascular and adherent
to eaeh other by means of scrofu.
ous deposit. Mucous lining o
leum at lower part ulcerated
Some small tubercles in kidnevs
and spleen.
Body well made; general
Iropsy. I.ungs (edematous, and
ower parts softened; right pleura
ilmnst full of yellow fluid. Old
ventricles of heart greatly dilated.
Mitral valve aomewhat thickened
and rigidatits margin, Aorticvalves
peritoneum. Kidneys very dark,
mrd, congested, and cysled. Liver
Spleen dark and very firm, with
an opaque, hardened capsule.
1
Has lost mui!b flesli; was
well and strong 3 months
ago. Has Utterlv felt weak
and out of health. Mud
»8ln in abdomen. BoweU
related; night sweats ;cong1
dry. Abdomen hard, tense,
tender. Signs of softening
tubercle in the apices of
ntigs. Appetite bad; slept
ladly. Sank gradually.
Admitted moritiund; hav-
"rora cough and dys]iniEB,
with genera! anasarca of
ower Umbs for about 10
«eeks.
^
- ^
i
2 ^^
1
1 J
£
S S
HUCOCB UEUBRANE OP THB BTOHACH.
s = s
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MUCOUS MEUBRANE OP THE STOMACH.
tis-h !• =
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isili^ III
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«|«lll«;|-|||||||s| *|.|;|
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MUCOUS UEHBHANB OF THE aTOMAUM.
S. " .5 ^ ■f ■= er| ■s 3
it
J III
PI
Ifjfll
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MORBID CBAN0E8 IN TUK
^s!i'»ri"il"-5|i^s:-ii|siii
"aBs-Sg e J S.-5, fc-5 g s £ gs£:Ea-=.g-g
-III" ii'sifss mmsi
Eii!iiiii"iii| r
3
MBRANE OP THE STOMACH.
i":;i|glis^=-.:s3|jtifis tills
l!-1|||5-slS| sttf '^-J^Kl Ifl^i
!i|f!i s^^ 8] i |ii mill I. iiy I
ytifill^''Ktlli:-:inHs illill
i;H'=si'§s-^l|||-|||i|-y|^|IJ|l'^S"g's|.|
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|.';Siil:-il||i': |«l
li-43=''S-;-;ii-|? 15-1
ll'llll-silpjl Jsl?
t|f|tl|i;||l||||
MUCOUS MEMBRANE OP THE STOMACH.
"ill i-^s ^ I i i i I ■i^'".1ll11| s-^ ii
l5|ila|.S'?agr. Ililstilsjill
i:
||'=e"I
"5^1
s si at ill
t«J^OE-?s-| I III
lllllglli,a jlllllilllillsl
MORBID CHANflES IN TUB
- Ill § .1 . li'S ft
« i s ■ " is .
tiilil
■S.Ssrg.'SSSSa^- ff^
"is""" 'i^^i .-atii
fiflf iyi||!i|!
^ 3 ga
Ilii^sI'ls'L*
iiii^iililj
MUCOtTS MEHBKANl! OP THE STUMA(
"S 3 g.1^ a S "-3 c, >.■= a «
I'ITI'IoT'^ "" ^^'^ ■^ I -g "^
lillftlll l^tlifllil
° "I
flu
J |2^-4ls:l l"t=silt,i|l-
Is 1alE''tJ ls;|°« ■""■3, -Sd
IJilljIsli 'JlljJilalllJ
UOHBID CHANOeS IN THE
^ E 4 t— '^e y ?^.S^15^ ""'^ E^^"2 "''n E -c S E -5
■|||S|S| l^g^lsSi^iE^ll
11 ^"2:^ § »E
MUCOUS MEHBRANS OP THE STOMACH. 131
iiiif||jlij}j iJliifi! tl!
^jl'st-lHIi-pl it:Miii su
lllllllfljllll
llifilflliti^sill ts;!-li11«l=
ill :i :|iiri iii-s i s -.UhSmii-i
siilflsiPSji;!?! ll-=f-^".-=liil
I'l's-slaii^Jir-^il'slll" His'z Sli
s l«5Slpi|fi"-?-iiisis :^*1!s "-
! = "j!ij-|i^!ppiljl iriC li«
MORBID CHANGES IN THE
Hii riii dii i i||iif II mi iPfi I
ililii^ini ipi^;iiti;.r!f 111
Ii1ll=! Ji-Mlfl: |i|||i|5
11 ill illJ!li|liUJ ■^'iSs-.-^S
MUCOUS MEHBKANE OF THK STOMACH.
S-D (b£-s 1..3-' ~ a "■e'S.S; " " = sg"- SEE "IT,
1
gested; a little old tubercle at
pleura. Heart, liver, kidneys, and
ipleen, healthy. Anterior edge of
iver rounded, somewhat ; surface
of capsule thickened, and adhereni
and pallid.
Body in good condition, mns.
cular. A large quantity of turbid,
dirty greenish sero-pumlent fluid
n right pleural cavity, hoth layers
coaled with recent lymph. Ribs
not injured. Both lungs quite
healthy. Heart rather large, but
healthy.
Hi
y.
his chest severely by a fall,
which caused much extrava-
Bation of blood over the right
ribs. He had suffered from
cough and pain in that side
a long time, was exceedingly
weak, and had ruined his
health by drinking. He looked
10 years older than he said ht
lieved his dyspnoea much, but
UOKBID CHANQEB IN TUB
1
Contracted except in splenic r^on, con-
tained some thin, feebly acid, chocolate
rather dirty, slaty aspect. Splenic region-
mucous membrane appears thinned, tubes
and there, with fatty contents, and uiiot
rather large cystic formations; these are all
which is traversed by a great number of
yellowish streaks, consisting of oily mole-
cules. Basement membrane perfect, with
verted into a mine grtnulir ind fibroid
lissne, containing celloid corpuscles and
much free oil. Here and there are seen
tubes whose outlet is obliterated. Pyloric
waited and lowerends gathered iniobunches,
with much granular and oily deposit under
[he basement membrane. There were a few
massy nuclear deposits.
Contained a great deal of acid, aemi-flnid
consisted of large quanlilics of di^bris of
food, mingled with very numerous frag-
ments of columnar epilhelial lining of
fosiute. There was some fissuring of the
surface in the splenic region, but no mam-
;
Limbs spare. Much fat on abdo-
men and among viscera. Both
duration in anterior edge of right
Uver healthy, some chronic thick-
enmg of its capsule. Kidneys
highlv granular, atrophied to one
half their normal sUe. Uterus en-
arged, retroverted, its cavity much
enlarged and lined by a bloody
coi^lum.
dnid of reddish colour in both
pleura, compressing lungs consi
derablj. Lungs, heart, and peri
cardium healthy. Peritonaaum much
1
•
1
1
!
■a
1
]
1
f^
i
s
s
1
1
1
1
i
s
E
= se .
HDCODB HEHBBANB OF
lsi'^ll|« __
iii/|i=: lilts. Ill s1|l».5?l
ISII^I^J ii|||lt|!||il||t|
Jlijiflil l;-iIl|3S5i;.-l:ll!.
liflll'''' iFlttttftlfltr^^
g - I 5-S
■Sa^£=e:Higo3=-s=*-ls
!Pim|i|ll|f^:|lii
ltllll|li!&liN|ililliP'f-fi
l-s 15:113111 alll^-i-slll^^s ill :.°2
HOBBID CHANQES IN THK
f!llAllll ill
ip&fn fill
l|.l?;".'|.3"|.J'l
hiiiiB
■S'5'5 8 SS
3 2f|-
Ijljil
3 I Ic
■^ln^l
lill^fj.'
HUCODS MEMBRANE OF THE BTOHACU
1-- 11
lisiiiif-irsii
!t!iii^t|itii
1111*1:5 isl "If
St
3
■J
i
l.a'll
Is Sl
l^Mllllii
iiiltri
1
■Si
ft
n
Had good health, eicept a
hydrocele, which had been
cured 2 or 3 years before.
Withoni previous ailment, ei.
cept pain in the back occa-
to swell, and face also. Aspect
aallon, nith red patches on
cheeks. Pulse quick, regular
Tongue pretty clean. No
evidence of diseaae in heart
nr lungs. Urine not albu-
minous, but he had all the
MORBID CHANQE8 IS' THE
t
f
s
1
mimmmmm
jil '=lti 4ii!! Ill
^rliliJpl!i|r!l!i 1,5
-4iii^iiiiiiiriiiiil
i
soft and greasy. Kidneys ralhei
granular and flabby, mottled and
vascular their cortices greatly
nasted io spots. Spleen soft.
Other organs natural. Then
was ft cavitv in the liver con-
taining matter Uke Ihe dfbri. of
lydatids.
tissue, with a lai^e mail involving
the rectum and hUdder. The
organs were hesllby.
Body (Edematous ; Some Beram
in peritonajuffi! blood generally
fluid. Slight effusion in pericar
dinm ; a long thin band of adhe
lion over miildleofrigbl ventricle
.BSBcls. Right tentricle thickened
and enlarged. Left of nalural
liie. Aortic valves— only 2—
thickened, their edges hardened
and involuted ; they were not efll
dent. Othervalveihealthy. Righ
lung everywhere adherent-, it
lower lobe gorged with black Wood
and serum; does not collapse; is
lOft and friable; its btvuchial
1
X
aspect of a man suffering from
renal disease. After about
14 days, diffuse cellular in-
he sank and died.
Suffered 2 years with dy.
senlery, and latterly hail as-
cites.
Subject to cough for 30
years, ever since he had
measles; spits blood instreaks
mingled with yellow thick
sputa; his legs swell; is
emaciated. Face dusky
swollen ; eyes prominent
Bomediarrhoui. Pleural fric-
tion was observed in both
backs. He got worse luddenly
and died 18 days after admia-
i
S S
t
S 5
I
J J
'?.
K
K
HttCOtTS MEMBRANE OF THE STOMACH. 141
ilii1ll«lllllillliPliJ^Jl-lii!li^
BID CHANGES IN THE
- |lp J :|.|
'":S2|_g:;Hlj|Hls -g"
■a »3 2-l-s g S- 3Si q „.2 o
■gte- I _
- 1 1 s * I -s
s°|i||i-^l|i-|| j_
MUCOUS MEMBRANE OE THE
^.s.s
Sl*5
llisfsli:!' ePIlli, i-i-fl-
i;i=llf:^il i»!!|li 111*
i-s,jjJlii:i "stjsjl "I-:!
TRiTHFIiJll ip-PTIFTTPs
^iils ill I'lJt! Islslisl'l l||i
... ... = ,.i,, 11= :||ii. 111
'j?s
11-111 '.Ssl'-lii^J^i-sl-Sfl" Sill
B >- S
UORBID CHANGES IN THE
11:1 V' Ittii
mm.
■face pale, smeared oter witU
e fluid, containing abundant
ulai- epithelium, and a Utile
leiiic and mid regions— lubes
Pyloric repon — lubes not
nlerslilial nuclear and fibroii
■=•=«= OS. =■0'" &= rSa -R^'obsSS*'
iij-il|.^g||ii ^il|tf-3^s
NTICOUS MEMBRANE l»P THE STOMACH
Il!fp|iilil|l1i=ti|:|ii
Fl ffilf .iHilyfiiriifi ■
i|fJillti!l|l!!illiiP!i|
I«t.i!t|--|gs§gf-5t2a|elli|
-SlllMllllill'lFfial-llll
ii^HiTi sililiss-i = |ls.s"'i|.a
SfSSg^u^g T! B^ as.! S^§ ItiS g ^ B^-a
^|i l6|i li|ii^||||liy:il
SB^a^?-^ S.3i Si's " S.^ t. 3 J o'S S W D
fpilMll sli|iF|^iii|fi|l
MORBID CHANOEH IN THE
Hill
il^l: '^^^-^IJi
-111
Sell.
■If lii^itl
aS^S
■a fi ■= c--g "
— iS a n tl P-'^ o ii B ■
wll^ a " e
Willis, fillsliyi ill
-llf'lla-s-'i-lKs^al iP
Iis.sllll°l1i6'llll| •'lil
MUCOUS MEMBRANE OF THE STOMACH. 147
iiiimm Pliiiilil iil:l|li*
sllSHIiRs lii-iiU^i 'i-ii:ii1i
TMlik-itrii^liJla^ic'li i'tf-lsis!
t»flll|ii."E-«1li|l?''.2'i° Iflil^l!!
f ,-|1T=|-.e|||'E.-j- 51|s^l,- Sttis's.',
'Ai
iPI=l!^" :"-'li&i-S^
.| fi u -S ■§
^j i" o.». .go "5 3 - I'a t."^ li"' s ».| 3 " "-ila ■
2 ^ a g » -S
MOH1IID CIIAN0E8 IN TH
4
1
•s
brane well marked. Mid region— tobeti
extremely vraated amid an infiltration of
nuclear deposits. Black pipuenl is depo-
sited in the stained spots, chiefly between,
but partly also within the tobes. Pylorio
region, tissue in aame slate, groups of
veliow pigment molecules here and there.
Splenic and mid region- tubes fairiy
ess obscured and atrophied by interstitial
healthy.
Surface presents several black, stained
spots, and contained much chocolate fluid of
acid reaction, generally pale. Splenic re-
gion— tubes tolerably healthy, but rather
lUered by self-diRestion ; blood lamed into
yellow pigment. Mid region— lubes healthy,
sltered in some parts by self-digestion ; at
one dark-Blained spot there were a vart
lumber of lai^ black grains within the
tubes. Pyloric region— tubes generally
i
1
1
cardial patch. Liver very firm and
cirrhoaed, with opaque capsule.
Spleen very soft, capsule opaque.
Kidneys very large, Bmoulb, with
nettled surfaces and swollen cor-
tex. Blood very fluid.
Body emaciated, pale. Bight
ung condensed in parts, and iide-
dilated, and their mucous lining
hicfcened. Left lung mnch con-
densed and congested, bronchi
dUatedandinOuned. Heart healthy
and liver. Kidneys rather wasted
and granular. Spleen solid, o(
dirty gray aspect on anterior
surface.
Heart-walls flaccid, cavities
oaded wilh blood. Lungs com-
pletely adherent to waUa of chest
their upper parts full of miliarj
tubercles, and much condensed
and spleen, lolerably healthy.
1
to contaiu blood. Blood bos
also passed in the stools and
vomited. He sank and died
years or more, had no dys-
dually.
was 1 week in union; not ill,
but feeble, and complained a
ittte of short breath. She
made no complaint of dys.
pepsia. Died qdetly in bed.
s
^ t^
n
s s
i
M. Ensor.
Ann Coles.
i
s s
MCCOC3 MEMBRANE OF THE STOMACH.
-iSi
|1!''^|-^1§| Ills i'"^ ^l-cl-^5 lli-ll"!
lB||^^-s:|"°l|l^|-:2|||l|g.|l=H^slfeii
It
MUCOUS H£MBHANE OF THE STOMACH.
St
II-
i'.i
ii|
!l||fl||E|f||l|j|
B 3 t "S -S,! g I -i ^'~. "^ " a g " *l)
ll- lliill I llfli
"■= "5^ . ^
iJil1tiPpll*|11 i' still
Llali
aisaJaa
■1
il
150^
EXPLANATION OF THE PLATES
Illustrating Dr. Handfield Jones*s Paper on Morbid Changes
in t?ie Mucous Membrane of the Stomach.
Fig-
1. Stomach tube, containing black pigment grains at its lower part.
3. Vertical section of splenic region of mucous membrane of the stomach,
the tubes all broken up, and their debris mingled with very nume-
rous black pigment globules. Some of the altered tissue is shewn
more highly magnified at {a). The mucous membrane was of a
very dark colour, in some spots black.
3. Vertical section of mucous membrane of stomach in mid-region. A
deposit of nuclear particles is seen encroaching on the tubes.
4. Vertical section of mucous membrane in the mid-region, showing
complete wasting of the tubes, and their place occupied by
granular and oily detritus and fat -vesicles. • The basement mem-
brane still persists.
5. Vertical section of mucous membrane in pyloric region, the tubes
much obscured and atrophied by interstitial nuclear deposit. A
cystic cavity with a caudate offset is seen in the substance of the
mucous membrane.
6. Vertical section of mid-region of mucous membrane of the stomach,
showing the tubes utterly wasted, and replaced by fibroid tissue.
At {a) are shown two cyst-Hke remnants of the tubes which were
brought into view by acetic acid. The basement membrane of the
surface still exists.
7. Atrophied epithelium from stomach tubes.
8. Catarrhal mucous from surface, it contains some cells from the tubes,
numerous nuclei, and a columnar particle.
9. Healthy epithelium ; cells from the tubes and columnar particles.
10. Vertical section of gastric raucous membrane in mid-region, showing
several papilloid masses of epithelium exuding from the follicles.
11. Vertical section of upper part of mucous membrane in the mid-region,
showing a cyst lying in a nuclear deposit. Diameter of cyst
^ inch. It contains nuclei, and a clear fluid.
12. Vertical section of mucous membrane in pyloric region: the tubes in
the upper part have disappeared, in the lower they are undergoing
fatty degeneration. Much oily matter is dispersed through the
tissue. The basement membrane is gone.
13. Vertical section of mucous membrane of mid-region of stomach.
The tubes are almost entirely obliterated, and the basement mem-
brane is lost.
EXPLANATION OP PLATES.
Fig.
14. Vertical section of mucous membrane of stomach in the mid-region.
(a) Basement membrane. (6) Tubes degenerating, (c) Corium
thickened, (d) Submucous tissue.
15. Eemnants of three tubes breaking up into granular tracts of nuclei.
16. Vertical section of mucous membrane of stomach about the mid-
region. The tissue is pervaded by nuclear deposit, and the tubes
are indiscernible. Nuclei are seen also in the corium and sub-
mucous tissue. At the lower part are two opaque fatty masses ;
the basement membrane is seen in the upper border.
17. Vertical section showing the mucous membrane fissured in two places
down to the corium.
18. Vertical section passing through a notch on surface of mucous mem-
brane : the notched part is covered by a layer of nuclei. Tubes
partially disintegrated.
19. Mucous membrane of stomach ; the tubes atrophied, the whole tissue
pervaded by nuclear deposit.
20. Vertical section of pyloric region, showing the villi and the nucleated
substance within them. This substance was abnormally developed
in the deeper part of the mucous membrane.
21. Vertical section of mucous membrane of stomach, containing a nuclear
mass in its substance. The mass is in part displaced, and an
empty cavity left. The surface is covered by a layer of disinte-
grated epithelium, (a) Separate nuclear particles.
22. Vertical section of mucous membrane, showing a large cystic cavity
occupying its whole thickness, (a) Basement membrane of sur-
face, (b) Mucous membrane pervaded by nuclear deposit.
{c) Corium.
A CASE
OF
FATAL ASPHYXIA,
CAUSED BY
THE DETACHMENT OF A DISEASED BRONCHIAL GLAND
WHICH WAS IMPACTED IN THE LARYNX.
BY
GEORGE EDWARDES, op Wolverhampton,
FELLOW OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, AND OF THE
ROYAL MEDICAL AND CHIRUROICAL SOCIETY OF LONDON ;
LATE SURGEON TO THE SOUTH STAFFORDSHIRE GENERAL HOSPITAL.
Received AprU 26th.— Read May 9tli, 1854.
Joseph Perry, about 8 years of age, of fair complexion
and light hair, considered healthy but delicate looking, was
playing with boys of his own age, when it is said he was
offended or struck by one of his play-fellows. He ran off
to tell his mother, and just as he got to his parentis house^
a distance of thirty yards, he rushed towards a female, whom
he met, and who thought that the child was in a fit. She
carried him quickly up stairs to his mother, who charged
the child with having swallowed something. This he
denied in a voice sufficiently strong and distinct to be
understood. His struggles became so violent that he could
scarcely be held by ordinary force. The head was often
thrown forcibly back, and the arms were extended occasion-
ally by a similar strong effort. The face was discoloured,
the countenance was extremely anxious, and he uttered the
expression more than once, '^Mother, I shall die" During
the struggling also, he cried out that he wanted to make
water, and almost instantaneously he voided both urine and
faeces. There was no cough, and the bystanders said there
152 FATAL ASPHYXIA CAUSED BY THE
was not any noise in the throaty but there were tumultuous
sounds about the upper part of the belly. My partner.
Dr. Bell, accompanied by Mr. Oatis, saw him about half an
hour after the seizure; at that period no sound could be
discovered by a hurried examination either in the trachaea
or chest, except the weak action of the heart; the
countenance was dark, and the child was making some
feeble struggles, evidently death-throes. In the hurry of
the moment there was no opportunity of getting any distinct
knowledge of the previous history, beyond the surmise that
the child had swallowed something.
Dr. Bell and Mr. Gatis immediately opened the trachaea,
when a little air issued from the opening, artificial respira-
tion was attempted for some time by means of a female
catheter, but without effect, as the child only gave two gasps
after the operation.
I assisted in the examination of the body seventy-two
hours after death. There were no marks of external
violence. The jugular veins on both sides were greatly
distended. On opening the chest, the tlings and heart
occupied their usual position, and presented their natural
appearances, except that the lungs were uniformly dark, and
greatly congested. Both sides of the heart were empty, ^
and there was an ounce of bloody serum in the pericardium.
Touching the under surface of the epiglottis, and extending
through the rima glottidis into the larynx, was a body about
an inch in length, of irregular thickness, and presenting
in its form something of an hour-glass contraction ; one end
was thicker and longer than the other; the substance was
whitish, and covered with mucus, and in appearance much
resembled a piece of chewed newspaper, being marked with
black or blueish grey lines, and clots, exactly as a piece of
chewed printed paper would appear. It was easily removed
from its position. On a further examination it was
evident that the body was a bronchial gland, broken up
irregularly, and adhering at the narrow part by cellular
tissue. Slitting open and tracing the trachsea, the spot
from which the gland had issued, was soon found ; it was
DETACHMENT OF A DISEASED BRONCHIAL GLAND. 153
on the posterior part of the right side, just above the
bronchial bifurcation. The opening was ragged and
irregular, and communicated with a cavity behind, suffi-
ciently large to contain a good sized nutmeg. The other
bronchial glands were normal, the trachsea contained some
frothy mucus, and the lining membrane was somewhat
congested.
There appeared to be no glandular disease in any part of
the body, nor was there the slightest appearance of tubercles
in the lungs. The stomach contained no food, but was
much distended with air.
The case is interesting, not only from its novelty, but in
many points of view. Did suppuration commence within
the gland, or was this a case of ulceration around the gland,
detaching it from its bed and opening a passage for it into
the trachsea ? Again, did the gland at once pass into the
trachsea, or was it a gradual process ? The shape of the
gland seems to indicate the latter process, and probably the
blow the boy complained of, or a sudden effort at play, was
the means of entirely disengaging it from the opening; the
expulsive efforts afterwards forced it into the glottis and
destroyed the child. In either case there appears to have
been no symptoms to point out the mischief which had been
going on in the child, who was represented by his parents
as having been free from cough, hoarseness, or difficulty of
breathing. As nearly as can be calculated, the time which
elapsed between the commencement of the suffocating feeling
and the death of the child, was half an hour ; hence there
could not have been complete closure of the glottis at first.
Indeed it is a question whether the obstruction to the breath-
ing was ever complete continuously, or was only to such an
extent as to prevent that ingress and egress of air, which is
necessary for the sustenance of life, each respiratory act
being so imperfect that the blood by degrees became
poisonous and unfitted to supply the nervous stimulus
required to maintain the hearths action to transmit the
blood through the lungs. Hence their dark and engorged
condition after death; and hence, probably, the want of
154 PATAL ASPHYXIA.
success in the attempt to inflate the lungs after tracheo-
tomy.
This case is also interesting in a medico-legal point of
view. False accusation might easily have been made;
indeed the boy in this very case complained of being ill-used
by his playmates, and had any of them been much older
and stronger than himself, there would have been great
difficulty in convincing the parents that the death of their
child had not resulted from violent and improper treatment.
Suppose two persons to have been quarelling and blows
were exchanged, during which a diseased bronchial gland
became lodged in the glottis of one of them ; he falls and
struggles as if suffocating, and half an hour afterwards
expires ; the presumptive evidence certainly would be that
the blows had killed him, and it might require a very careful
post-mortem examination on the part of a medical witness,
who had not seen the person before death, to convince
himself and satisfy a jury that a little whitish elongated
glandular body lying loosely in the larynx had been the
cause of death.
With regard to the treatment of the present case, I think
it is obvious that any means adopted at the period when
Dr. Bell and Mr. Q-atis saw the patient would have proved
ineffectual; tracheotomy, however, appeared to offer the
best chance, and probably if performed earlier, might have
saved the boy's life.
The Bronchial Gland as it appeared after it was taken from the glottis.
REMARKS ON A PECULIAR FORM
OF
TUMOUR OF THE SKIN,
DENOMINATED
" PACHYDERMATOCELE,"
ILLU8TUATED BY CASES.
BY
VALENTINE MOTT, M.D., C.L.D.,
EMERITUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF NEW YORK.
Received May 9th.— Read June 13th, 1854.
•
The dermoid tissue is liable to a greater variety of dis-
eases than any other in the body, and although a great
number have been carefully and accurately described, there
are some which have not yet received the attention of pro-
fessional men. Among the latter, there appears to me
to be none more remarkable than that which is the subject
of the following paper.
The following five cases illustrate this peculiar state of the
dermoid and subjacent tissues, and I propose to give to
it the nsLine pachydermatocele; all have been congenital, the
disease beginning in a brown spot or mole, as such appear-
ances are generally called when small, and increasing with
the years of the individual, until, as in three of my cases,
they presented hideous and disgusting deformities.
The morbid structures have all been more brown than the
surrounding integuments, with a flabby feel, very like a relaxed
and very emaciated mamma. In several of the cases there were
two and three layers or stories, as in the one upon the neck
and shoulder, resembling the fanciful and successive turns of a
156 REMARKS ON A PECULIAR FORM OF
tippet, or three separate folds of a rich maroon velvet
curtain as may be seen in Plate II.
They do not appear to possess any great degree of
vascularity, neither having veins visible upon the external
surface, nor diminishing in size much after being detached
from the body, therein diflfering essentially from the nsevus
maternus, or aneurism by anastomosis. The cases of the
two boys, in which the disease involved extensively the scalp,
one side of the face, and extended below the base of the jaw,
presented by far the greatest amount of blood-vessels.
On cutting a slice transversely, or making an incision
into these growths, the sub-dermoid structure to the eye
seems to be hypertrophied areolar tissue, with very little
evidence of blood-vessels running through it. From their
general appearance and duration, there is no evidence
whatever of anything malignant in their structure or
tendency. In one of the cases there was a return of the same
kind of tumour upon the same spot, namely the head, though
to a«less extent, demanding a second excision, and it returned
again, and is now of the same shape and character as at first.
In another patient, a boy, the same disposition to return was
observed during the granulating process, but it was com-
pletely conquered by the patient and skilful application of
compressed sponge and the roller bandage. In the other
three cases there was no disposition whatever to a reproduc-
tion of the disease.
The sense of feeling was somewhat diminished below the
natural standard in all of the cases. In only one was there
any ulcerative action, and this arose entirely from want
of attention to personal cleanliness. The largest required
to be carefully washed every day with soap and water, then
well dried and powdered with some farinaceous substance.
If this was neglected for one day an acrid fetid discharge
took place, soon leading to excoriation.
Case 1. — A young woman, set. 24, of an excellent con-
stitution, and uniformly good health, requested me to ex-
amine something which had existed from her earliest
TUMOUR OF THE SKIN. 157
recollection^ and was steadily increasing in size. She said
it was a swelling on the left side, not attended with the
least pain, and only annoying to her from interfering with^the
comfortable and symmetrical arrangement of her dress. She
evinced a delicacy in showing it, arising more particularly from
some story of a fancy of her mother as to the cause.
On exposing it to me I found a flat tumour from four to
six inches in length, and nearly the same in breadth,
banging completely pendulous. It was situated on the left
side a little obliquely, about four inches below the mamma,
and on a line with the axiUa. It was about an inch in
thickness, of a brown colour, and on closely inspecting the
surface it was found to be beautifully striated, the striae
running in a serpentine manner. This was visible on both
sides, and scores of dark points were distinctly to be observed
sprinkled over the striae. These spots were of the size of
common and large pins' heads, and when picked out might
be said to resemble dry melanotic formations. {Vid.
Plate II.)
At her request the growth was removed by two incisions,
each about eight inches in length, so as to include every
part of the abnormal growth. It was dissected from portions
of the pectoralis major, senatus magnus anticus, and latissi-
mus dorsi, each of which muscles appeared perfectly sound
and natural. The extent of integument left did not allow
the edges of the wound to be closely approximated. The
considerable extent of surface thus lefb uncovered granulated
and healed very kindly without any untoward circumstance.
There was not any return of the morbid growth.
Case 2. — ^This occurred in a maiden lady, more than 40
years of age. The growth was situated on the lefb side,
identical in shape, size, and attachment, with that described
in the former case, but ulcerated in its entire extent, which
condition also extended to some little distance around its
attachments. The ulceration had been spreading for several
years, and the fetid odour it emitted was singularly loath-
some. This I am confident must originally have been
158 REMARKS OP A PECULIAR FORM OF
occasioned by the personal filth and disgusting neglect of
the patient; who though wealthy^ was the most insupportable
miser I ever knew^ denying herself and servant the most
common necessaries of life.
The fetid mass was removed by a simple dissection from
the subjacent muscles^ as in the former case. Several small
arteries were secured after the tumour was removed. A
larger surface was from necessity left to be healed by the
second intention.
The first four days after the operation were passed with-
out any untoward or unfavorable circumstance. After this
she became excessively anxious about her property^ accusing
her servant and family of robbing her, and saying that she
should be left penniless and in want. Fever now set in,
which in a few days assumed a typhus form, and soon termi-
nated her life.
Case 3. — A. R, a boy, aet. 14, of a sound constitution,
consulted me about a hideous and disgusting deformity of
one entire half of his head and face. It consisted of three
layers of tumours, from the crown of the head to some
distance below the base of the lower jaw. One of them
was formed in or involved the eyelids, which were carried
down to the lower part of the face. When this portion was
raised up the ball of the eye appeared sound in the bottom
of a canal three or four inches in depth.
No pain at any time had been connected vrith this ab-
normal growth. As the mother states, it was noticed
shortly after birth on the side of the face in the form of a
small point or pimple, from which all the loathsome and
disgusting deformity has proceeded. This boy was so ex-
ceedingly deformed and monstrous, as to be an object of
terror to the children in his vicinity, and of sport and
amusement to the idle boys.
These tumours had the same brawny feel as the rest, and
the cuticle had a dry corrugated and scaly appearance where
it covered the striae and irregularities of the hypertrophied
tissues underneath. This abnormal mass now involved the
TUMOUR OF THE SKIN. J 59
scalp of one side of the head, from the vertex to the centre
of the forehead, one half of the nose, the upper and lower
lips, the whole side of the face, and extended below the base
of the lower jaw, back to beyond the ear. At all these
points it seemed to occupy the whole of the dermoid tissue,
and was continually increasing in size. {Vid, plate II.)
The age at which he had now arrived gave him
interest in his personal appearance, and induced him to ask
if some change could not be made in it for the better by a
surgical operation. This I attempted to do at his request,
apprising him and his parents at the same time that the
operation was attended with danger.
After being put under the influence of chloroform, an
incision was commenced at the vertex of the head, and
carried down over the forehead, inner canthus of the orbit,
centre of the side of the nose, by the edge of the angle of
the mouth, over the chin, and a short distance upon the
neck. Another, from the same point above, reached along
by the ear, and passed over the base of the jaw, and met
the other upon the neck. One or two transverse incisions
were afterwards necessary to put the parts in a favorable
state to bring the edges together and adjust them by
sutures.
The redundant reticular or areolar tissue, was so great,
and appeared so completely to occupy the place of the
natural structures, that not a muscle of the face could be
found after the most careful dissection. It seemed, indeed,
as if this growth extended to the membrane of the mouth.
The vascularity far exceeded my expectations for such a
tissue. A great number of arteries required ligatures.
The quantity of blood lost was considerable from the
arteries, as also from several large veins. Adhesive
plaister, lint, and a double headed roller, completed the
dressing.
Shortly after recovering from the anaesthesia, an anodyne
of morphine was exhibited to allay pain and quiet the
mental agitation under which the boy laboured. Much of
the wound healed by the adhesive process, and what suppora-
160 REMARKS ON A PECULIAR FORM OF
tion followed seemed to favour the melting down and
destruction of the superabundant morbid tissue that re-
mained.
During all the process of granulation and cicatrization^
firm pressure was kept up by a roller carefully adjusted to
all parts of the head and face.
He recovered completely from the operation^ and his
improved appearance was greatly calculated to give satisfac-
tion to himself and family^ as well as to gratify the operator.
It was not many weeks, however, before there were striking
evidences of a renewal of the growth, in defiance of the
continued pressure of the roller bandage.
The growth was gradual but constant, and after some
months its magnitude was so considerable as to induce him
again to request its removal. Its size was now far less than
at first.
Putting him under the influence of chloroform, several
incisions were made about the face and side of the head, in
order to remove as much of the morbid part as possible, as
well as to secure more points for cicatrization. He lost
less blood in this than the first operation, and com-
paratively but few arteries required ligatures. No untoward
circumstance attended the after treatment, and again much
benefit resulted to the patient in appearance.
This improvement, however, was but temporary, for in
less than a year the morbid formation commenced again to
grow, and now has attained a magnitude, which though less
than that of the original growth, makes him a hideous
object.
Case iv. — ^A boy in exceUent health, about twelve years
old, consulted me about a tumour on the opposite side of the
face, identical in all its physical characters, but of less size,
than that in the preceding example. As his appearance was
far from being beautiful, he was also desirous of being im-
proved by an operation. This I consented to do ; preparing
him, however, with the probability that it would return.
This growth commenced also in early infancy, and, from all
that could be learned, was probably congenital.
TUMOUR OF THE 8KIN. 161
While in a state of anaesthesia^ I made several extensive
incisions^ and cut more liberally into the surrounding healthy
integuments^ with a view of not only removing as far as pos-
sible all the abnormal tissue^ but to obtain also the benefit
of the two reparative processes of granulation and cicatriza-
tion. The benefit of this soon became very apparent^ but
the permanency of the cure may be greatly attributed to the
persevering use of compressed sponge^ and tight bandaging
over the granulating surface by my estimable friend. Dr.
Batchelder. About six years have now elapsed, and there
has not been any return of the morbid formation.
Casb v. — This was truly a monstrous morbid production.
Though disgusting, and even frightful, to ordinary beholders,
there was in its organization and external characters, looking
at it as a morbid growth, something symmetrical and beau-
tifuL From the mother's statement it was observed soon
after birth.
Miss S — , set. about 45 years, of robust country health,
came to me from the western part of the State of New York,
as she said, to show me a tumour, and to know if it could be
removed. From the compact and regular arrangement of
her dress, the impression on my mind at once was, that it
was of no great importance as to size. My astonishment was
not a little excited, as soon as she removed her dress from
the chest and neck, not only from the immense size of the
mass, but that it could all be so completely stowed away, as
not to disturb the apparent symmetry and harmony of her
proportions.
The tumour was of a dark brown or copper colour, of a
soft elastic feel, very much resembling a collapsed lung or
a placenta. It hung in beautiful and fantastic folds, like
the convolutions of a tippet over the neck, shoulder, and
chest. There were five of these folds or stories, the smallest
above, the longest or broadest below.
It was attached to the healthy integuments behind and in
front of the ear — directly under its lobe — to the entire
XXXVII. 1 1
162 REMARKS ON A PECULIAR FORM OF
extent of the side of the neck from near the nucha to
the edge of the larynx and trachea^ to the whole line of the
clavicle and middle of the upper bone of the sternum, over
the shoulder, part of the scapula, and reaching upon the arm
to near the insertion of the deltoid muscle — over the entire
pectoralis major to the middle of the sternum and ensiform
cartilage, and to the upper part of the rectus abdominis
and latissimus dorsi, with a portion of the serratus magnus
anticus. The lowest loose fold hung a little below a line
with the umbilicus. The entire length of the tumour was
twenty-one inches, its breadth eighteen inches.
Stating to her that I thought it might be removed, she
requested to have the operation performed, if there was, as
she said, ''any chance of her life.'' Being made. insensible
with chloroform, the operation was performed in the following
manner :
An incision was made a little below the tumour, across the
lower part of the deltoid muscle, and the growth was dis«
sected from this muscle to the top of the shoulder, then from
the side of the thorax and upper part of the abdomen, then
from the whole line of the clavicle, the upper part of the
sternum, the back of the neck, and from the trapezius
muscle. It was now detached from about the ear, and the
dissection continued towards the front part of the neck,
in the direction of the course of the stemo-cleido mas-
toid muscle, until it terminated by an incision over the
mesial line of the larynx and trachea in their entire length.
In all this extensive dissection many arteries required
ligatures, and some of them were of considerable size. The
most remarkable, and indeed monstrous, were two veins
entering the sub-clavian, no doubt the external jugular
in its anterior and posterior branches, each apparently
separate. Their size was the greatest I ever saw
in any superficial veins, being each not less than my fore-
finger. They were running close together, and were seized
successively the instant on being cut with the forceps, and
were tied, to prevent the admission of air, from which, on
one occasion, I had seen frightful and almost fatal effects.
TUMOUR O? THE SKIN. 163
As the tumour originated on the upper part of the
neck, these two enormous superficial veins were probably
the principal channels for returning the blood from the
whole abnormal mass. They lay side by side, as they went
through the deep cervical fascia, but probably just on enter-
ing the subclavian, they united, as is usual in the normal
state.
As the operation was considerably protracted, from the
extensive superficial dissection, and the large number of
arteries which required ligatures, some exhaustion followed,
but she was not alarmingly depressed at any moment,
and quickly rallied when the anaesthesia was allowed to
pass off.
After she had suflSciently recovered for any vessels to
show themselves, and all bleeding was stopped, the wound
was dressed with dry lint, compresses, and a roller to make
a moderate amount of pressure. Shortly after the operation,
an anodyne was administered to allay pain, and lessen
irritation. For several days afterwards, until suppura-
tion was established, she had considerable fever, but much
less than I anticipated from so extensive a wounded
surface. The fever was readily moderated by appropriate
treatment, and the granulating process was soon esta-
blished.
After between two and three weeks of progress in heal-
ing, everything seeming to be as favorable as could be
wished, erysipelas spread itself extensively around the
edges of the wound, accompanied by a vitiation of the
discharge, and a sweeping away of the healing mate-
rial.- This state was accompanied with great disturbance of
the brain and nervous system, with low fever, which immi-
nently hazarded her life. By suitable and appropriate local
and general treatment, the storm was arrested, the nervous
and vascular system returned to a quiet and tranquil state,
the wounded surface assumed a healthy appearance, tind all
again promised well.
Two or three weeks were now passed in an improving way,
but on a sudden, without any physical cause, another attack
164 KEUAKKU ON A PECULIAK POBlf 07
of erysipelas btirst upon the healthy and healing wonnd,
affecting the general system^ and pnt us all back again. This
was^ however^ less violent than the former attack^ and pro-
duced less havoc among the granulation. These seizures
were from an atmospheric cause, erysipelas being at this
season very prevalent in private as well as hospital
practice.
By means of general tonics, nutritious diet, and stimu-
lating dressings, the wound soon assumed again a more
favorable appearance, and began to granulate and cicatrize.
From the immense extent of the ulcerated surface, and the
enfeebled state of the general system, various changes in
the constitutional and local treatment were from time to
time called for. These changes were properly met, and the
wound had so far healed in three months that she
was enabled to return home — ^a distance of more than two
hundred miles.
On getting to her native village, she rapidly improved ;
and was soon enabled to return to her accustomed duties.
I have heard several times of her, and within three weeks
had a letter from her. The wound for some time was en-
tirely healed ; but, at the time of her last letter, there was a
small point that had ulcerated, without, however, manifesting
any disposition to spread, or any peculiarity in its character.
The critical period of life at which she had arrived, indicated
to my mind the propriety of establishing an issue somewhere :
I accordingly directed one to be made in the sound arm.
There has never been any appearance of a reproduction
of the tumour ; nor is there any at the present time. It is
now about five years since the operation was performed.
This tumour weighed nine pounds, and was twenty-one
inches in length, and eighteen in breadth.
My colleague. Professor Lovett, has kindly furnished me
with the following notes of the microscopical appearance of
one of the tumours :
*' The specimen appears to me to consist of an hypertrophy
of the skin, and of the subcutaneous cellular tissue.
TUMOtTB OF THE SKIN. 165
'^ Under the microscope I find nothing but an exaggera-
tion of the natural tissues. There are no evidences of a
malignant formation.
" The diseased structures seem to me to be quite analogous
to what was noticed in the case of elephantiasis of the leg^
which I exhibited to you during the winter/'
CASE
OF
DISTORTION OF THE SPINE,
WITH
OBSERVATIONS ON ROTATION OF THE VERTEBRA AS A
COMPLICATION OF LATERAL CURVATURE.
BY
THOS. HODGKIN, M.D., L.R.C.P., and WM. ADAMS, F.R.C.S.
ASSISTANT SURGEON TO THE ROYAL ORTHOPJBDIC HOSPITAL;
DEMONSTRATOR OF MORBID ANATOMY AT ST. THOMAS*S HOSPITAL.
Aeeeired May 9th.— Read June STth, 1854.
9 — . '
The late Gideon Mantell was born at Lewes, in the
county of Sussex. He applied himself at an early age to
the exploration of the fossils of the upper chalk formation^
and on coming to London to attend the medical school of
Bartholomew's Hospital, he took with him a collection of
considerable extent.
On his return to Lewes to engage in practice, he still
continued his investigations, and it will easily be believed that
his labours were great, inasmuch as his most remarkable and
successful researches were carried into the Gait and Wealden
rag, — in the hard and untractile masses of the latter he
discovered the remains of those lost gigantic reptiles, the
Megalosaurus and Iguanodon.
Impaired health and other causes induced him to transfer
his practice from Lewes to Brighton, and some time after he
again moved, and settled at Clapham, where his personal
labours as to his favorite pursuits were restricted to the
collection and examination of the few fossils to be met with
in the gravelly alluvium.
It appears that in 1842, being 52 years of age, he suffered
from excessive pain in the back, inducing him to apply an
opiate liniment and leeches. Then he was thrown from his
168 DISTORTION OF
carriage upon the back ; and the symptoms are reported to
be aggravated^ and numbness came on in the left foot.
After this it is stated that he attended a case of con-
cussion of the brain^ and walked home in an intensely cold
night, when the lower limbs became paralysed^ the bladder
required the catheter. The rectum was also affected^ and
enemata were used.
After many weeks the power of voluntary motion slowly
returned ; sensation followed with intense neuralgia. The
tumour in the back rapidly increased^ with supposed fluctua-
tion. During the period of nine months. Listen, Brodie,
Bright, Lawrence, Stanley, Coulson, &c., were consulted.
The tumour became slowly harder, and almost disappeared.
Sensation continuing to return, the tumour again became
larger and harder, and the abdominal aorta wu pushed
forward.
The cachectic appearance of the patient led to the
suspicion of the formation of a malignant tumour in con-
nexion with the bodies of the vertebrse, an idea which was
subsequently abandoned.
By degrees the neuralgia became less frequent, but
Gideon Mantell notes his health as broken up.
To relieve intense suffering, he sometimes resorted to
anodynes, but it does not appear that he ever prescribed
large doses for himself. On the last occasion a dose of
this kind, which is believed to have been taken on an empty
stomach, produced the symptoms of narcotic poisoning,
which proved fatal.
Report of the Post-mortem Examination of Dr. Mantell.
By Mr. Wm. Adams.
Died 10th November, 1852. Examination of tbe body 13th November.
A tall, well- developed, muscular man. As the region of
the spine was the chief seat of interest, from there being
a history of a tumour or swelling having existed in the left
lumbar region, supposed to be dependent upon, or connected
with disease of the spine, the body was first placed in
THB SPINE. 169
the prone-position^ and the dissection commenced from
behind.
There was a slight fulness in the left lumbar region near
to the spine; but certainly nothing amounting to a tumour.
On pressure^ three or four hard and prominent nodules
could be felt^ one above the other^ situated from 2 to 3
inches to the left of the spinous processes^ and on a level
with them.
No lateral deviation of the spinous processes could be
detected in any portion of the column. Both sides of
the chest were fully and symmetrically developed. No
tilting of the pelvis was apparent, though some deviation
might have existed, as exact measurements were not takeu^
nor were the pelvic bones thoroughly exposed by dissection.
It may therefore be said that the body did not present any
remarkable external appearance. No obvious deformity
^dsted. In pursuing the dissection from behind towards
the abdominal cavity, it soon became apparent that the
prominent nodules felt in the left lumbar region were the
apices of the transverse processes of the lumbar vertebrae
projecting backwards, and rising to the level of the spinous
processes. The bodies of the lumbar vertebrae could also
be felt projecting in an arched form, with the convexity
outwards to the left side, and at first suggesting the idea of
a hard tumour connected with the vertebral column. No
morbid appearance presented itself in the soft tissues in this
region. The subcutaneous cellular tissue and fat were
everywhere perfectly healthy ; the muscles were apparently
quite healthy. There was no trace of any morbid growth,
cyst of abscess, or of any other inflammatory process having
existed in the neighbourhood ; no thickening, adhesion, or
other alteration in any of the soft tissues.
The body was now placed on the back, and the abdominal
cavity was laid open in the usual way. A very severe lateral
curvature of the spine to the left side in the lumbar region
was now seen. The curved portion of the spine presented
also a remarkably twisted appearance, from lateral rotation
of the vertebrae, so that the transverse processes of the left
170 DI8T0ET10N OF '
side projected backwards^ as above described, whilst those
on the right side projected inwards towards the abdominal
cavity. The anterior common ligaments of the spine, and
the cellular tissue on the anterior and lateral aspects of the
vertebrae, and also the psoae muscles and other tissues, were
in a perfectly healthy condition.
No traces of abscess or of any old inflammatory process
could be found, and it being impossible that a lumbar
abscess could have formed and disappeared without leaving
some structural changes in the soft tissues surrounding the
spine, it may confidently be asserted that no abscess ever
existed.
A portion of the vertebral column, consisting of the three
lower dorsal and all the lumbar vertebrae, with a portion of
the sacrum, was removed for separate examination. Viewed
from its posterior aspect, the apices of the spinous pro-
cesses of this portion of the spinal column are seen to
present a lateral deviation to the left side, the most promi-
nent part of which, viz., between the spinous processes of
the second and third lumbar vertebrae, measures rather more
than half an inch from a vertical line drawn from the spinous
process of the tenth dorsal vertebrae to that of the first sacral
bone. This distance is easily diminished to a quarter of
an inch by a slight efi'ort at straightening, and this, as
above stated, was not apparent previous to its removal,
though as measurement was not then adopted, it might
have existed.
The bodies of the spinous processes, however, instead of
passing directly backwards, incline towards the left side, so
that in this aspect, the sides of the spinous processes are
brought into view. This deviation exists in the spinous
processes of the first, second, third, and fourth lumbar
vertebrae, but to a much greater extent in the second and
third than in the others, the angle of lateral inclination in
these being nearly 45°. The spinous process of the fifth
lumbar vertebrae retains its normal direction.
The transverse processes of the first, second, and third
lumbar vertebrae on the left side project backwards towards
THE SFIN£. 171
the skin at about an angle of 45°, and rise exactly to the
level of the apices of the spinous processes. The transverse
process of the fourth lumbar vertebra is very remarkably
altered both in direction and form; instead of passing
directly outwards, it curves upwards as a horn-like process,
and approaches the transverse process of the third vertebra
within three eighths of an inch ; and instead of being flattened
in its antero- posterior aspects, it is compressed from above
downwards, and expanded horizontally towards its free ex-
tremity. This expanded portion measures three quarters of an
inch in its transverse diameter, and its under surface presents a
shallow cup-like depression, coated with a thin layer of fibro-
cartilaginous substance, giving to it a well-marked character
of an articular surface. — There can be but little doubt that
this transverse process rested upon the crest of the ilium,
articulating with it, as it were, by its expanded extremity,
the form of which, together with its altered direction, being
the result of long-continued pressure from the superincum-
bent weight. The oblique section made through the sacrum,
in removing the parts, has unfortunately not included the
corresponding portion of the crest of the ilium, but the above
supposition is rendered exceedingly probable by the general
aspect of the parts, and is also supported by the existence of
a similar condition in the specimen closely resembling the
present from Mr. Caesar Hawkinses collection at St. George's
Hospital. In this preparation the pelvis is. attached, the
corresponding transverse process presents a precisely similar
appearance, and has only been slightly separated from the
crest of the ilium, upon which it obviously rested, in the
process of drying. The transverse process of the fifth
vertebra has been sawn through in removing the parts, but
from the portion still remaining, it must have been either
absorbed to a great extent, or remarkably altered in form
and position.
The traaisverse processes on the left side are widely sepa^
rated from each other, whilst those on the right side are
proportionably approximated. The distance between the
transverse processes of the first and second lumbar vertebrae
172 DI8T0ETI0N OF
on the left side measures rather more than an inchi and
between those of the second and third vertebrae one and a
quarter inches* The tranverse processes of the third and
fourth yertebrse on the same side are remarkably approxi-
mated, in consequence of the altered form and direction of
the latter above described ; they are only three eighths of
an inch apart. The transverse process of the fifth vertebra
has been sawn through in detaching this specimen. The
distance between the transverse processes of the first and
second lumbar vertebrae on the right side is only half an
inch ; and between those of the second and third vertebrae,
and also of the third and fourth vertebrae, rather less than
half an inch. The transverse processes of the fourth and
fifth vertebrae on this side appear to be abnormally separated
firom each other, to some extent, the distance between them
measuring fully an inch.
The articular processes have evidently been subject to a
very severe amount of irregular pressure and strain, tending
towards displacement, but they have at the same time be*
come gradually altered in form, and considerably enlarged
by the growth of bone, principally at the margins of the
articular surfaces, which have thus been retained in contact.
These appearances are well seen in a transverse section
which has been made of one of these joints. The process
by which the enlargement has taken place appears to be
similar to that by which the enlargement of the articular
extremities of bones (in the hip and knee-joints for example)
has been shown by Mr. Wm. Adams to take place in the
affection called chronic rheumatic arthritis. (See 'Trans.
Path. Soc.,' vol. 3, paper by Mr. Wm. Adams.)
Viewed from its anterior aspect, the specimen exhibits a
very severe degree of lateral curvature to the left side, in-
volving the bodies of the two lower dorsal and the three
upper lumbar vertebrae, with a remarkable degree of rota-
tion of the vertebrae in the same direction, and also a very
perceptible lateral curvature to the right side, involving the
bodies of the two lower lumbar vertebrae and the sacrum ;
so that a distinct double curvature exists. The most pro-
TBB SPINE. 173
minent point of the upper and larger curve is the interver-
tebral substance between the second and third lumbar
vertebrae. If a vertical line be drawn from the centre of
the tenth dorsal vertebra, and carried downwards through
the centre of the sacro-lumbar articulation, it will be found,
that the distance between this vertical line, and the most
prominent part of the lateral curve, viz., the outer
border of the intervertebral substance between the second
and third lumbar vertebrae, measures three and a half
inches.
The deformity of the spine cannot, however, be correctly
described as a direct lateral curvature, for the bodies of the
first, second, thirds and fourth lumbar vertebrae are also
rotated in a horizontal or transverse plane towards the left
side, so that the anterior surfaces of the bodies of the
second and third vertebrae have a lateral, rather than an
anterior aspect. The rotation in these vertebrae, extends to
very nearly 45® from the median plane. The eleventh and
twelfth dorsal, and the first and the fourth lumbar vertebrae,
are also implicated in this lateral rotation. In this anterior
aspect of the specimen, it is also apparent, that absorption
of the bodies of the vertebrae in the concavitiep of the
curves, especially of the second and third lumbar vertebrae,
and also of the intervening intervertebral substance in the
upper curve, and of the intervertebral substance between
the fourth and fifth lumbar vertebrae in the lower curve, has
taken place to a considerable extent. In these situations,
there is not the slightest indication of any inflammatory
process having existed.
Viewed in profile, or from its lateral aspect, the natural
curve of the spine, in the lumbar region, is seen to be
reversed ; and instead of presenting a convexity forwards,
the three upper lumbar vertebrae, together with the twelfth
dorsal, present anteriorly a concave outline. This is not
produced by any absorption or destruction of the bodies of
the vertebrae anteriorly, but is evidently caused by the very
remarkable degree of rotation above described ; by which
the natural anterior convexity in this region, is made to
174 DISTORTION OP
assume a lateral position^ as if the spinal colamn had been
laterally twisted on its vertical axis^ the centre of motion,
being fixed at the apices of the spinous processes.
A vertical section^ from side to side, through the bodies
of the vertebrae^ exhibits the following appearances. There
are no indications of any destructive disease, such as caries
or necrosis, having existed in any of the vertebrae. The
cancellous structure appears to be healthy in all parts. The
chief alteration in the bones, is a diminution in thickness
of the bodies of the vertebrae in the concavity of the lai^r
curve, the result of absorption from unequal pressure ; this
chiefly affects the bodies of the second and third lumbar
vertebrae, each of which is diminished a quarter of an inch
on the right or concave side : these vertebrae each measure
one and a quarter inch in thickness on the convex, and one
on the concave side of the curve. The wedge-shaped form
thus given, to a certain extent, is less than might have been
expected from the severity of the curve externally.
The intervertebral substances between the bodies of the
and first and second, and of the second and third lumbar
vertebrae, have been, to a considerable extent, absorbed in
the concavity of the curve ; these cartilages each measure
five eighths of an inch on tj^e convex, and less than a quarter
of an inch on the concave side of the curve ; this, also, is
evidently the result of unequal pressure ; there are no indi-
cations of ulceration having existed.
It is therefore obvious, that the lateral curvature is
chiefly dependent upon absorption of the intervertebral
cartilages. The intervertebral substance between the
third and fourth lumbar vertebrae, is uniformly diminished
in thickness to a quarter of an inch through its
central portion, but expanded at each side, where
it has been free from pressure, in consequence of a
certain amount of lateral sliding, or displacement of the
body of the third vertebra from the fourth; the lower
border of the third vertebra projects beyond the upper
border of the fourth vertebra, three eighths of an inch
towards the left or convex side ; and on the opposite side
THE SPINE. 175
has receded, as it were, from the edge of the fourth ver-
tebra to a like extent. The body of the fourth lumbar
vertebra, by a similar movement of lateral displacement,
also projects beyond the body of the fifth vertebra three
eighths of an inch to the left side.
The intervertebral substances between the fourth and
fifth lumbar vertebrae, and between the fifth vertebra and
the sacrum, are diminished in thickness, in an opposite
direction, to those between the second and third, and the
third and fourth lumbar vertebrae. The cartilage between
the fourth and fifth vertebrae measures rather less than a
quarter of an inch on the left side, and rather more than
three eighths of an inch on the right side ; so that it is
diminished a quarter of an inch on the left side. The car-
tilage between the fifth vertebra and the sacrum is dimi-
nished in the same direction, but to a somewhat less extent.
The bodies of the fourth and fifth vertebrae are not dimi-
nished in thickness on either side : thev both measure five-
eighths of an inch in thickness in all parts. The wedge-like form
of the last two intervertebral cartilages described will be seen
to produce a curvature to the right side, the arc of which
would include the bodies of the fourth and fifth lumbar
vertebrae and the first bone of the sacrum.
As minor alterations in the osseous structures, indicating
a reparative process, may be mentioned a considerable
increase of thickness and density of the compact structure
forming the outer surface of the bodies of the vertebrae in
the concavity of the curve, and also of the adjacent portion.
of the cancellous tissue similar to the thickening of the
walls of the long bones in the concavities of the curves
following rickets in early life, and no doubt answering a
similar purpose of buttress-like support. The superior and
inferior margins of the bodies of the vertebrae are also
enlarged so as to form projecting lip-like processes.
It was not considered advisable to lay open the spinal
canal for the purpose of examining the condition of the
cord, though such a proceeding might appear to be neces-
sary to the explanation of some of the symptoms in this
176 DISTORTION OF
case. The section for this purpose could not have been
made without totally destroying the specimen as one of
deformity^ and in this respect it presented so many features
of interest and practical importance, that their preservation
was considered to outweigh the chances of discovering any
morbid changes in the spinal cord.
The fact of the greatest practical importance which this
specimen illustrates and clearly proivesj is one which I
believe has not hitherto been described, viz., that a very
severe degree of lateral curvature of the spine with trans-
verse rotation of the bodies of the vertebrae, accom-
panied with lateral absorption of the bones and intervertebral
cartilages to a considerable extent, and attended with all
the distressing symptoms of the most aggravated form of this
affection, may exist, with only a very slight lateral deviation
of the apices of the spinous processes; in short, that the
severest degree of deformity of the spine may exist inter-
nally, without the usual indications in respect of the devia-
ation of the spinous processes externally.
When it is borne in mind that all surgeons are in the
habit of relying upon the relative position of the apices of
the spinous processes to the median line, as an index to the
existence or non-existence of lateral curvature, the impor*
tance of the fact above described cannot be over-estimated
in the diagnosis of this affection. In this particular case
it does not appear that any of the very eminent physicians
and surgeons who examined Dr. Mantell suspected the
existence of lateral curvature of the spine; the general
opinion seems to have been that destructive disease existed
either in the bodies of the vertebrae or inteiTertebral sub-
stances and was accompanied by lumbar abscess, which one
surgeon proposed to open. The fact, however, that the sup-
posed lumbar abscess made no progress after the lapse of
a considerable time, from one to two years, but on the
contrary rather diminished, threw considerable doubt and
obscurity over the case ; still in the absence of the great
diagnostic symptom of lateral curvature of the spine, viz.,
lateral deviation of the apices of the spinous processes, this
THE SPINE. 177
affection was not suspected ; and it does not appear that the
hard nodules felt in the lumbar region^ and once supposed
to be the lobules of a tumour connected with the bodies of
the vertebree, were at any time recognised as the transverse
processes of the vertebrae. This can hardly be matter of
surprise, when it is remembered that it was the only positive
symptom, taken in conjunction with the general aspect and
inclination of the body, by which the affection could have
been diagnosed, and up to the present time such a condition
has not been described as diagnostic by any authority on
curvature of the spine. A careful study of the present case
will, however, enable us to diagnose a similar condition in
alike case, with as much certainty as if the ordinary indi-
cations were present.
The condition of the spine here described as transverse
rotation of the vertebrae, the centre of motion corresponding
to the apices of the spinous processes, I do not find mentioned
by any modern authority on these affections ; but it appears
to have been observed by the late Dr. Dods, of Bath, who,
so far as I know, was the first to direct the attention of the
profession to the subject of rotation of the spine in lateral
curvature. In the year 1824, he published a somewhat
remarkable work, entitled, ^ Pathological Observations on
the Rotated or Contorted Spine, commonly called. Lateral
Curvature.'
The author endeavoured to show, that the condition
generally described as lateral curvature, was really one of
transverse rotation of the vertebral column, the natural
flexures of which were by this movement brought more or
less into view posteriorly instead of laterally ; that, in fact,
as an object becomes changed in its appearance from change
of position, or by varying the point of sight, so an altered
position, the result of rotation of the spinal column, pro-
duces the deceptive appearance of lateral curvature. At
page 98, he observes, " It does not happen in all cases of
contorted spine that the whole column is moved round ; if
it were so, we should have invariably the profile of its three
flexures brought into view in the manner described, whereas,
xxxvii. 12
178 DISTORTION OF
it is well known that there are frequently but two of them
observed/' At page 23^ he remarks, '^As the spine is
rotated spirally^ and not as upon a pivot^ the profile of its
flexures will be imperfect/' Dr. Dods appears to have been
led to the existence of rotation by observing what was
really the most positive symptom in the case now under
consideration, viz., the prominence of the transverse pro-
cesses in the left lumbar region. He states, page 101,
'^ During the course of my operations (alluding to friction^
&c.,) upon several patients, I was struck in all of them,
(for they were all contracted to the right side,) with a con-
siderable bony hardness and projection on the left side of
the loins, raised nearly to a level with the spinous processes ;
and this I found to be the case in the patients whose spine
exhibited little or no apparent curvature in the loins, as well
as in those in whom the apparent curvature was very great."
After the muscles had been relaxed by friction, Dr. Dods
was enabled to satisfy himself that the bony prominences
were produced by the transverse processes of the lumbar
vertebrae, which could be distinctly felt and counted like the
spinous processes. In these cases the transverse processes
of the same vertebrse on the opposite side could not be felt,
and appeared to have sunk inwards completely out of reach.
Reasoning upon these facts, and considering that a direct
lateral curvature of the column could only affect the trans-
verse processes by separating them on one side, and approxi-
mating them on the other, 4hout altering thJir transversity
with respect to the body. Dr. Dods concluded that such a
condition could only be produced by a movement of trans-
verse rotation. He also traced a similar condition in the
dorsal region, evidenced by the oblique position of the
spinous processes, also described in Dr. MantilFs case, and
considers the rotation sometimes to extend to the cervical
region.
From the above observations, it would appear that Dr.
Dods had met with and recognised the precise conditions
now described in the specimen under consideration ; for he
specially mentions the fact, in some cases, of the transverse
THE SPINE. 179
processes rising to the level of the spinous processes in the
lumbar region, with ^' little or no apparent curvature in the
loins /^ and we have thought the evidence of this fact of
suflScient importance to justify his views being brought under
the notice of this Society. They are evidently the result
of careful and original observation, though the explanation
of the phenomena observed, their mode of productiop, and
the indications for, and methods of treatment given, are in
many respects erroneous, like the great majority of patho-
logical doctrines tested by the experience of thirty years'
scientific inquiry; it would, however, be out of place to
advert to these points in the present communication.
In the cases alluded to by Dr. Dods, his attention was
probably directed to the existence of rotation in the lumbar
vertebrae by prominence of one of the shoulders, and other
points of defective symmetry which may or may not have
existed in Dr. Mantell during life, though not obvious after
death. By some it has been remarked, that *^ he looked as
if he suffered from curvature of the spine.'' There is no
account, however, of any examination having been made
with special reference to this point. From an observation
made by Sir B. Brodie, in a clinical lecture delivered by
him in Dec, 1846, and published in the ^ London Medi-
cal Gazette,' it would appear that M. Guerin was familiar
with the appearances described in the specimen exhibited.
Sir B. Brodie observes, '^ At a very early period, and even
before the lateral curvature is very distinct posteriorly, the
bodies of the vertebrae are actually twisted to one side.
This curious circumstance was pointed out to me by M.
Guerin, who has some preparations, in which the fact is
very perceptible." In M. Guerin's first memoir, ^ On the
Treatment of the Deviations of the Spine by Section of the
Muscles of the Back,' published in 1843, page 18, he alludes
to the modifications of form dependent upon the double
influence of vertical displacement caused by lateral flexion,
and of horizontal displacement caused by torsion. He was
evidently aware of the existence of rotation, but he does not
allude to it as at any time coexisting with an absence of
180 DISTORTION OF THE SPINE.
lateral deviation of the apices of the spinous processes^ as
in the present instance^ and therefore it is not mentioned in
its most important practical bearing upon the diagnosis of
lateral curvature. He had probably noticed what may now
be described as the disproportion between the internal and
external curvatures, also a most important fact^ and one
of frequent^ if not constant occurrence^ in all the more
severe forms of lateral curvature of the spine.
Rotation of the vertebrse, or a spirally twisted condition
of the vertebral column^ as a complication of lateral cur-
vature, is alluded to by many English writers on this
affection^ but generally only as a passing observation, little
or no practical importance being attached to it, and by
several of the principal authorities of the present day it is
altogether omitted. There can be no doubt, however, of
its frequent, if indeed it may not be said, its constant
occurrence as a complication of the more severe forms of
lateral curvature; and when it exists in any considerable
degree, it constitutes one of the chief difficulties of treat-
ment. All the instruments at present so generally used,
which make direct lateral pressure on the convexity of the
curve, must tend to increase the mischief in such cases,
though by their effect in flattening the ribs, this result may
not at first sight be apparent.
180^
EXPLANATION OF THE PLATES
Illustrating Mr. Wm, Adams's description of a Case of
Distortion of the Spine,
Plate I.
Anterior view of the Spine of the late Dr. Mantell, vide p. 172.
Plate II.
Posterior view of ditto, vide p. 170.
ON
GOUT AND RHEUMATISM.
THE DIFFEEENTIAL DIAGNOSIS, AND THE NATUEE
OF THE SO-CALLED EHEUMATIC GOUT.
BY
ALFRED BARING GARROD, M.D.,
PROFESSOR OF MATERIA MEDICA, THERAPEUTICS, AND CLINICAL MEDICINE,
AT UNIVERSITY COLLEGE;
PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL.
Received June 26th.— Head June 27th, 1854.
In this country, there is no one, I believe, whose opinion
would be looked upon as an authority, who holds the doc-
trine of Chomel, that gout and rheumatism are one and the
same disease ; still there are very many who, allowing the
complete separation of these diseases, in their characteristic
forms, yet entertain an idea that one disease is able to
merge into the other ; and that a morbid condition to which
the name of rheumatic gout has been given, is not uncom-
monly produced — a condition whose name is familiar both
to the profession and the public, but of which it is difficult
to find a precise description.
Can one disease merge into the other? Can rubeola
become scarlatina, or scarlatina rubeola? Doubtless it
is not unfrequently difficult to diagnose certain cases of
either of these diseases, at any rate, simply from the pre-
sent condition of the patient ; it is not, however, customary
to designate such cases by the compound name of rubeolo-
scarlatina, or scarlatino-rubeola ; for we feel confident that
each of these diseases is produced by a special poison, and
has its own special pathology, although the symptoms pro-
duced by one may occasionally simulate those of the other.
It may be possible, but it is certainly extremely uncommon.
182 ON GOUT
for h patient to suffer from the two affections simul-
taneously : to such a case the compound name above men-
tioned might be appropriate. So, also, it may be asked, can
rheumatism merge into gout, or vice vers& ? Has not each
of these affections also its own special pathology, and is not
the name of rheumatic gout, as generally applied, simply a
cover for our want of knowledge of the precise affection
under which any given patient may be labouring? I
would not for a moment be thought to deny the possibility
of a gouty patient becoming affected with rheumatism ; but
I have no hesitation in affirming, as the result of long ex-
perience and attention to the subject, that the disease is
extremely uncommon, and that the cases ordinarily desig-
nated by that name are not those in which such a double
disease is present.
The subject of the diagnosis of these masked cases, is, I
consider, one of very great importance — important both as
to the prognosis and especially to treatment ; it is also a
subject of no small difficulty.
To diagnose acute gout, when it occurs for the first time
in a rich man, of middle age, and affecting the ball of the
great toe only, preceded by dyspeptic symptoms, and accom-
panied by turgescent veins and oedema of the inflamed
part, is a matter of the greatest ease ; so, also, to diagnose
acute rheumatism in a poor girl, with most of the larger
joints inflamed, together with the endo- or pericardium, pre-
ceded by rigors, and not accompanied with oedema of the
affected joints, is one of no great difficulty, even to a tyro in
medicine ; but the case becomes altered when either gout
or rheumatism has never been very decidedly marked, or
when, from repeated attacks, the symptoms have lost all
their pristine characteristics.
To clear away the difficulties in making such a diagnosis,
to enable the two diseases to be separated when they
assume their masked forms, and to show the impossibility of
the frequent occurrence of a disease which can correctly be
eallod "rheumatic gout/' is the object which I shall en-
tlt^avour to accomplish in the present communication.
AND RHEUMATISM. 183
lu a paper published in the Society^s Transactions for 1848,
entitled " Pathological Condition of the Blood in Gout and
Rheumatism, &c.," I threw out the following suggestion
with regard to the diagnosis of gout and rheumatism :
" Might it not, in doubtful cases, be possible to determine
the nature of the affection from an examination of the
blood V At that time, the amount of evidence on this
point which I was enabled to bring forward was very
limited, amounting only to four cases of gout, and the same
number of rheumatism. Since that period, although I have
not made known any further evidence on the subject, from
an unwillingness to form conclusions from few or imperfect
data, I have by no means been unmindful of the matter, and
have lost no opportunity of putting the question to a most
searching investigation; the results of which, founded as
they are on 1 77 examinations of the blood, taken from 148
separate patients, will be given in the present paper.
I have avoided referring here to any case of either gout
or rheumatism, when the blood has not been examined, al-
though during the time in which these have been accumu-
lating, very many others have come under my care.
The plan adopted for tabulating the patients, has been
to divide the cases into four different classes.
1. Articular affections, in which was demonstrated the
presence of an abnormal amount of uric acid in the blood.
2. Articular affections, in which the absence of uric acid
in the blood was shown.
3. Articular affections, proved to be closely connected
with urethral affection.
4. Affections non-^articular in character.
The examination of the blood for uric acid, was in
general performed in the manner described in my paper
read before the Society this session, which I named the
*' Uric Acid Thread or Fibre Experiment,^' except in certain
cases where the acid was separated and weighed, and the
results of which are detailed : the history, symptoms, &c., of
each patient are taken chiefly from my Hospital Case-Books,
during the time I have been attached to the Institution as
184 ON GOUT
physician; some few have been the results obtained from
patients in private practice ; but^ as must be evident to all^
on points connected with the condition of the bloody and
requiring accurate investigation, no patients offer the same
facilities as those residing for the time in the wards of an
hospital.
It will be seen^ in referring to the following tables^ that
the blister fluid has occasionally been analysed as well as the
blood; sometimes, but very rarely, in lieu of that fluids
from what I have shown in my last communication to the
Society, the condition of the blood may be deduced from
that of the blister-serum, when certain precautions are
taken.
AND RHEUMATISM.
185
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J. Z. Rnmsey.
AND RHEUMATISM.
189
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AND RHEUMATISM. 191
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AND RHEUMATISM. 211
Table I contains a more or less detailed account of 47
patients suflfering from articular disease, in whom the exa-
mination of the blood was made, and it will be found that
there are many peculiarities both in the history of such
patients, and in the symptoms exhibited by them ; the most
important are as follow :
Sew, — Only two patients out of forty-seven affected
with articular disease, whose blood contained an abnormal
amount of uric acid, were females.
Age. — ^The average of the ages of those patients in whom
this point was noted, amounting to thirty-two in number,
was forty-seven years; this applies to the ages of the
patients when in the hospital^ and not when first attacked
with the disease.
Hereditary predisposition. — In twenty-six cases, it was
found that thirteen, or one half, could trace what they
called gout to some close blood relation. In patients in
hospitals, it is not unfrequently difficult to get very clear
accounts of family peculiarities, or hereditary predispositions ;
in the remainder of the cases, no account of such matters
had been noticed.
Habits y 8fc. — Out of twenty-eight cases where the habits
of the patient were particularly given, twenty-one acknow-
ledged themselves to be free livers, and for the most part
took largely of malt liquors, either with or without spirits,
not uncommonly combined. Seven said they were very
temperate, but most of these, which included the two female
cases, strongly inherited the articular affection.
Occupation.'-^The occupation was noted in thirty-three
cases ; and it is very singular to observe, that eight of these
or nearly twenty-five per cent., were painters or plumbers,
at any rate had made use of lead in their work, and had
been affected with lead disease. Any comment on this
point, however, we must defer to a subsequent paper. The
occupations of the remaining patients were very miscella-
neous : — brewers^ men and wine-coopers, gentlemen^s ser-
vants, cabmen, &c. No one occupation, with the above
exception, appeared to have much influence ; but in those
212 ON GOt'T
in which the patients could readily procure malt liquors, the
cases were the most numerous ; but this refers more espe-
cially to the habits of the individuals.
Exciting Causes of Attack. — The causes to which the
patients especially referred the attacks under which they
were suffering at the time, were noted in eighteen cases.
Many could assign no cause for any given attack. Of these
eighteen patients, seven referred it to over-drinking, two to
drink combined with fatigue or debility, two to cold, one
to cold and debility, two to severe injury ; in two, it came
on during the course of some chest affection, and in two
other cases, after epilepsy. So that over-drinking seems to
be by far the most powerful exciting cause ; and it is not
every patient who will readily acknowledge to this fault, or
it is most probable the proportion would have been much
greater.
Symptoms f Affection of ball of Great Toe. — In thirty-five
cases, the fact as to whether the patient had suffered from
any special affection of the ball of the great toe, either in
the attack under consideration or any prior one, was
particularly dwelt upon ; and it was found that, in twenty-
nine cases, the great toe affection had been well marked, in
two it was absent ; in the remaining four, the feet only
were affected, and in some of these latter the presence or
absence of the special affection of the toe could not be
positively asserted. It will be observed that in the first
attack this part was more especially selected by the disease.
(Edema of affected parts. — (Edema occurring on the sub-
sidence of the inflammation of the affected parts, especially
the dorsum of the hands and feet, or where the surface was
much affected, was noticed in twenty-four cases to be pre-
sent. It was never stated to be absent; in many cases,
desquamation of cuticle was found — a symptom doubtless
intimately connected with the oedema.
Concretions or Tophaceous Deposits, or Chalk Stones. — In
thirty-seven cases, the presence or absence of concretions of
urate of soda upon the surface, or in such situations as to
be undoubtedly recognised, was noted, and they were found
AND RHEUMATISM. 213
to te present in seventeen patients — absent in twenty.
Some points of interest with regard to their locality were
also observed. In the above seventeen cases, they occurred
in the ears (on the surface of the cartilages) alone^ in seven
cases ; in ears and around joints, &c., in nine ; and in one
case only could they be recognised in the other parts of the
body, without also being present in the ears. Of this
peculiar selection of the ear for the deposition of urate of
soda, I have seen many examples in private patients,
of which I have notes ; and I may state, that they fully
agree with the results contained in the table. These de-
posits may vary very greatly both in number and size, from
one to eight or ten, and from the size of a small pin^s head
to a pea ; they are beautifully crystalline, and of a consist-
ence varying with the time at which the matter was thrown
out. A representation of an ear, pretty freely studded with
deposits of urate of soda, will be seen in the annexed
drawing ; it was made from a patient in No. 1 Table, whose
blood was examined, and found to be rich in uric acid.
Acute Heart Affection^ Peri- or Endocarditis, — In no one
case was recent endo- or pericarditis found. Some had
slight old valvular disease.
From a review of the symptoms exhibited by patients in
Table I, it is evident that the majority of them are such as
no physician would hesitate to affirm to be those of true
gout, and in some, whose symptoms were not so striking
during the attack under consideration, the history at once
gives the clue to the nature of the disease : still there are a
few, where no hereditary predisposition could be discovered,
who never had the great toe specially affected, who never
appeared, from their own statements, to have lived very
freely, whose symptoms might, according to the definition
of the diseases gout and rheumatism usually given, be re-
ferred either to gout or rheumatism, provided that the con-
dition of the blood, or the effects produced upon the disease
by remedies, were not taken into consideration ; and it is
the true nature of such cases that it is the especial object
of the present communication to endeavour to elucidate.
214 ON OOUT
XcTv many patients called the disease under which they
were labouring^ rheumatic gout, and on questioning them^
aaid that their former medical attendants had so called it :
as a rule, however, it was not the really difScult cases which
were so named, but those in which the patient had formerly
suffered from acute gout, but which disease had, in process
of time, merged into a chronic affection. Not unfre-
qucntly, these so-called rheumatic gout patients exhibited
abundance of chalk-like deposits of urate of soda in different
parts of the body. With regard to the amount of uric acid
contained in the blood, I think that it bears no direct proper*
tion to the intensity of the local symptoms; often, I believe,
an inverse ratio may hold good, as I have reason for sus-
pecting that the local inflammations tend greatly to destroy
this body, and therefore, in cases where the joint affection
has remained a long time, we should not be surprised to
find it greatly diminished. This was evidently the case in
the blood taken from the patients Rurasey, Heath, and
Rous, in Table I. At first, in Heath^s blood it was not
detected, but this, probably, was from the too rapid drying of
the serum; it being in summer, and I not then taking
all the precautions enjoined in my former communication
this session. I hope to recur to this subject at a future
time, but I would advise, that in cases of this kind,
the serum should be put up in rather large quantities, as
from a fluid drachm and half, to two drachms, and allowed
to dry carefully and slowly. The presence of other inflam-
matory disease will probably also tend to lessen the amount
of uric acid in the blood, as appeared to be shown in
Johnston^s case : here, however, the joint affection was by
no means of a severe character.
Table II, contains an account of thirty-five cases of
articular disease, not connected with urethral aflection, and
in which no uric acid was found in the blood. On
making an analysis of these cases similar to the last^ the
following facts are eliminated.
•••: ••: •••
• • • • ! • •
• • . •••
AND RHEUMATISM. 216
Sex, — Out of the thirty-five patients,, twenty-one were
females, and fourteen males.
Age. — In thirty cases the age was determined, and the
average was thirty years ; as in Table I, the ages were those
of the patients at the time of the attacks for which they
were admitted.
Hereditary Predisposition, — In twenty-four cases where
an account was obtained as to the existence or non-existence
of hereditary predisposition to the disease under which the
patients were suffering, it was found, that its existence could
be made out in eight cases, its non-existence in fourteen,
in two there was considerable doubt.
Habits of Patients, — Of twenty-seven cases, twenty-six
considered their mode of life very regular, and that they
took no unusual amount of malt liquors, wine, or spirits.
In one case the patient had lived freely, and taken a con-
siderable amount of alcoholic fluid.
Occupation, — ^No peculiarity was observed on this point
in any of these patients.
Exciting Causes of Attack, — In eighteen patients, some
cause of the attack was ascertained : of these, sixteen re-
ferred it to direct exposure to cold, and two to debility. In
no case could excess of drink be ascertained to be the ex-
citing cause.
Symptoms, Affection of Great Toe. — In thirty-one cases,
where the symptoms of the present and prior attacks were
given, thirty had never experienced any great toe affection,
in one patient only was it stated to have occurred, and
then the plantar surface of foot was also much affected, and
during the attack, which was the first, the joints of the upper
extremities were inflamed equally with those of the lower.
(Edema of the inflamed parts. — The presence or absence
of this symptom was noticed in thirty-one cases. In
twenty-seven it was absent, and in four only present to a
marked degree.
Concretions of Urate of Soda or Chalk Stones. — Not pre-
sent in any case examined, though particularly looked for in
those in which the symptoms are detailed.
i
216
ON GOUT
Aeuie Heari Affection, Peri- or Endocarditis, — In thirty-
one cases examined, recent peri- or endocarditis was present
in thirteeu, and absent in eighteen patients.
As will at once be seen, the majority of these cases were
such as physicians wonld pronounce to be true rheumatism,
simply from a consideration of the symptoms : in some, the
histories would readily clear up the diagnosis, but, as in
Table I, a few remain, where the condition of the blood must
be looked for to enable us clearly to refer them either to
gout or rheumatism.
The most important results obtained from Tables I and
II may be conveniently summed up as follows. In
Articular Affection with Uric Acid Blood.
The average age of patients was
The males formed ....
Hereditary predisposition was traced
Free living and drinking had existed
Painters or plumbers formed .
Diink acted as the exciting cause
The great toe had been specially affected
No great toe affection
Doubtful.
CBdema noticed
Deposits of urate of soda
Acute cardiac affection
47 years,
about 95' per cent,
in 50-0
75
24*3
in 39-5
82-9
5-7
11-4
68-5
45-9
none.
In Articular Affections {Non-urethral) with the Absence of
Uric Add in the Blood,
The average age ... .
was 30 years.
The males formed . . . •
but 40-0 per cent.
Hereditary affection was traced
in 33-0
Cold acted as an exciting cause*
88-8
(Edema noticed
12-9 „
Acute cardiac affection .
. . 41-9 „
Deposits of urates of soda
none.
Great too especially/ affected in
none.
' And alcoholic fluid did not appear to be either a predisposing or exciting
cause.
AND RHEUMATISM. 217
In Table III will be found the results of the examination
of the blood in 6 patients; in whom, although the joint
affection simulated very closely true rheumatic disease, yet
were separated from the cases in Table II on account of
a clear relation being established with urethral inflam-
mation ; it was not thought necessary to enter into detail
with regard to these ; suffice it to say, that the larger joints
were generally most affected, that in none was cardiac
affection present, and that the febrile disturbance was by no
means proportionate to the joint affection, when compared
with genuine acute rheumatism, thus separating them from
the cases in Table II ; and from those in Table I, the want
of special great toe affection, and the absence of uric acid in
the blood, at once serves to remove them completely.
All the patients in this Table were males.
Table IV gives the results of the examination of the
blood from sixty patients suffering from various diseases, and
it will be noticed that uric acid was stated to be absent in
forty-seven, and present in thirteen. On making an analysis
of these thirteen cases, it is found that five were patients suf-
fering from albuminuria, temporary or permanent, a disease
which, as I have observed in a former paper, may or may not
be accompanied with excess of uric acid in the blood; and the
above results fully confirm my former statement, for we also
find in Table lY other cases of the same disease where no
uric acid was discovered. One was a case of cholera, and
during collapse both urea and uric acid are retained in
the circulating fluid (I might have given other analyses
in this disease, showing this fact, but they have already
been brought forward in a paper on the 'Pathological
Condition of the Blood in Cholera/) In a specimen of
blood from a surgical ward, stated to be from a patient
with inflammation of the eye, a trace of uric acid was
exhibited by the thread experiment; nothing was known
of the case, whether gouty or not : again, a few crystals
were seen in a case of a man with pneumonia, and much
in one with broncliitis, — with regard to the pneumonic pa-
218 ON OOUT
tient, it could not be discovered that he had ever had gout,
aud a very small amouDt oaly of the acid was fouud j the
bronchitic man, although nothing is stated in his history w
to any hereditary predisposition to gout, yet exhibited pecu-
liar nervous symptoms not at all unlike those which precede
a gouty attack, and these perhaps may be explained by the
condition of the blood. In Table I is contained a case
which bears upon this subject; the patient, Clubb, was
admitted for chest affection, bronchitis and emphysema; the
blood was examined, and found loaded with uric acid; the
aftectiou did not yield to the ordinary treatment for bron-
chitis, but after a few days the cheat symptoms almost
instantaneously vanished upon the appearance of gout in
the great toe and knee.
With regard to the remaining four cases, marked x, x,
I may state, that they were not suffering from articular
disease; sad the nature of the affection is withheld on ac-
count of the subject having much interest, and being at
present under investigation.
We must, in the examination of blood taken from various
patients, expect to find now and then some uric acid, although
its presence may have no connexion with the disease under
which the patient is suffering ; for when once the gouty dia-
thesis is established, the blood, even in the intervals of the
attacks, seldom becomes pure : this remark applies, no doubt,
with much greater force to cases in which tophaceous deposits
hare taken place, and perhaps more to the asthenic than
sthenic forms of the affection ; for it is in such cases, more
particularly, that the amount of uric acid eliminated by the
kidneys is found so greatly below the normal average. It
will be observed, that all the patients suffering from non-
articular disease, and in whose blood uric add was found,
were males; this point is interesting, when connected with
the fact of the much greater frequent^ of gout in the male
than in the female sex. I have, however, occasionally seen
the niost severe forms of gont, with excessive chalky deposits,
in the female.
In conclusion, as we have found that the blood in every
AND RHEUMATISM. 219
patient suflfering from genuine gout^ contained an abnormal
amount of uric acid, and that in acute rheumatism such was
not the condition of this fluid ; and again^ that in all cases
which could be traced up to gout (although the symptoms
exhibited at the time might not be very characteristic), uric
acid was present, whereas it was absent in those cases where
no such phenomena could be found, I think we shall in
future be fully justified in considering this condition of the
blood as not only a most important, but even a pathognomonic
sign, and one more to be depended on than any of the other
symptoms taken separately ; and that in an otherwise doubt-
ful case, where the diagnosis rests between gout and rheuma-
tism, the presence or absence of this acid in the circulating
fluid (determined either from the examination of the serum
of the blood or blister exudation) may be looked upon as
decisive of the question. I have little doubt, but that many
of the cases of rheumatism which have been described by
different authors, especially the capsular form of Dr. Macleod,
are really gouty in their nature. Many, however, are
neither gouty nor rheumatic, and evidently closely connected
either with urethral affection or purulent condition of the
blood. It will be seen, that the specific gravity and
reaction of the blood has been noticed in the majority of
cases ; with regard to the latter property I may state, that I
have always found it alkaline, both in gout and rheumatism,
and I am perfectly confident that the opinion which has
been held by some, to the effect, that in acute rheumatism
it becomes acid, is completely erroneous. On calculating
the specific gravity of the serum of the different bloods, re-
duced to a uniform temperature, the average was found to be
rather less in gout than in rheumatism, but to so small an
amount that nothing valuable in diagnosis could be obtained
from it. It would also be necessary, before placing any
value on this fact, to eliminate from the calculation certain
cases in which the specific gravity of the blood might have
been altered by other causes than the diseases under con-
sideration. With regard to the urine of gout and rheumatic
patients, nothing is mentioned in the present paper; the
220 ON GOUT AND RHEUMATISM.
omission has been intentional, for I do not consider that our
present knowledge of the subject is su^cient to enable us
to make use of it in the diagnosis of obscure cases of these
diseases. The difference between the condition of gouty and
rheumatic urine becomes characteristic only when the other
symptoms or signs are so. Much that is erroneous on this
subject is doubtless often entertained, the appearance of
copious deposits of urates being taken as indications of excess
of uric acid in the blood ; the converse, however, is more
frequently correct, and impurity of the blood firom urates
is usually dependent on their deficient elimination by the
kidneys.
PosTscEiPT. — October 10, 1854.
Since the above paper was read, I have examined the
blood in fourteen cases. In four patients there was an
abnormal amount of uric acid. Three were males : all had
had a special great toe affection : two had chalk stones in
ears and around joints : one was a painter, and had suffered
from lead colic. In five cases, where the symptoms were
those of genuine acute rheumatism, no uric acid was de-
tected : the remaining six were cases of a miscellaneous
character, and the blood was free from the acid.
CASE
OF
TRAUMATIC ANEURISM
OF THE
OPHTHALMIC AETEEY,
CONSEQUENT ON INJURY OF THE HEAD,
CURED BY LIGATURE OP THE COMMON CAROTID ARTERY.
BY
T. B. CURLING, F.R.S.,
SUROEON TO THE LONDON HOSPITAL.
Received June 27th.— Read June 27th, 1854.
The relation of the ophthalmic artery to the optic nerve
is 80 close^ that any serious enlargement of the vessel must
be very liable to affect the fimction of vision, and it is
therefore fortunate, that the artery is so situated, and so
well protected, as to be very little subject to disease or in-
jury. It appears, however, to have suflfered in a few
instances of injuries of the head, and as the changes which
take place under these circumstances have not been par-
ticularly noticed, I venture to submit the following case to
the consideration of the Society.
J. M., set. 49, a labourer, was admitted into the
London Hospital, March 24th, 1854, with a fracture of the
clavicle^ and considerable hemorrhage from the right ear,
and labouring under the symptoms of concussion. He was
by no means a robust man^ and his hands were contracted
and crippled by rheumatism. It appeared, that he had
fallen from the top of a stack of wood, seven feet in height,
and pitched on his right shoulder and right side of the head.
222 TRAUMATIC ANEURISM OF
He was stunned by the fall^ and remained qnite uncon-
acious until after his admission into the hospital. There
were only slight marks of contusion on the head^ and
no evidence of fracture of the skull. Shortly after being
placed in bed he vomited^ and he remained in a semi-
conscious condition^ with a feeble pulse^ for several hours.
The head was shaved^ a cold lotion kept to it^ and a smart
purge given. On the following morning he was more con-
scious, and after remaining for three days very restless^ he
seemed to be improving. The hemorrhage from the ear
was followed by a serous discharge for about a week^ and
by total deafness of the right ear^ and he complained of a
dull aching pain on the right side of the head. In about a
week after the accident, the face was observed to be drawn
slightly to the right side, but the tongue could be protruded
straight out of the mouth. He was blistered behind the
right ear, and ordered to take small doses of calomel ; and
as he was in a weak condition, his diet was improved. In
a fortnight later, the paralysis of the right side of the face
had nearly subsided, and the pain in the head had dimi-
nished. About the beginning of May, I noticed a little in*
flammation of the conjunctiva of the right eye, attended
with slight chemosis. For this, a lotion consisting of a
weak solution of the nitrate of silver, was ordered. The
injection of the conjunctiva and chemosis continued, how-
ever, to increase, and the eye-ball was observed to be
prominent. I then suspected that some mischief was going
on at the bottom of the orbit. There was also more pain
in the head. An issue was made behind the ear, and the
nitrate of silver lotion to the eye was discontinued.
Fomentations were substituted, and two leeches were ap-
plied to the right temple, and repeated two or three times.
This relieved the pain in the head, but had no eflfect on the
eye.
May 22d» — The eye-ball protruded so much, that I was
induced to make a careful examination of the orbit, which
led me to detect a pulsation on placing the finger on the
upper lid, and pressing gently on the globe. The proptosis
THE OPHTHALMIC ARTERY. 223
was more marked two days afterwards, and a very distinct
bruit was heard when the ear was placed against the patient's
right temple. He also described the pain in the head as a
distressing throbbing sensation. Vision was not all im-
paired ; but he had very little power of moving the eye.
He was kept at rest in bed, with the head elevated, and a
small bladder of ice was applied over the orbit ; but this was
so uncomfortable, that it was discontinued after two days.
3lst. — A consultation was held to consider the propriety
of tying the carotid artery. The patient had lost the left
eye from cataract ten years before, which rendered it of
greater consequence to save the right. The sight of this
eye was somewhat impaired, but as he could see, with a
little difficulty, to read small letters, and vision was not de-
cidedly injured, and the proptosis had not perceptibly
increased for two days, it was decided to wait.
June 2d. — Finding the eye getting more prominent, and
vision becoming impaired, the pupil being widely dilated, I
determined on tying the right common carotid artery. The
ligature was applied on the vessel in the upper third of its
course. The pulsation of the eye-ball was at once arrested,
and the man was relieved of the beating pain in his head.
A dose of morphia was given at bed-time.
3d. — The man had slept only one hour. He experienced
pain in swallowing, and had slight twitchings of the mus-
cles. The eye was less prominent, but vision was not so
good as before the operation.
4th. — He was unable to discern the objects before him;
indeed, his vision was lost. He could only distinguish between
light and darkness. The pupil was dUated, and the iris did
not act on exposure of the eye to strong light. He was
otherwise doing well, and felt no pain in the head.
5th. — ^The chemosis and redness of conjunctiva had
nearly disappeared, and the projection of the eyeball had
almost subsided. The cornea was dull and hazy. The
grey iris was slightly discoloured, of a greenish hue, and the
pupil was widely dilated, of an irregular oval form from old
adhesions. He experienced considerable intolerance of light.
224 TRAUMATIC ANEURISM OF
On the 8th the cornea was obsenred to be less hazy, and by
the 11th had become nearly clear. Vision was returning,
but the intolerance of light continued. He had quite reco-
vered the power of moving the eyeballi which had subsided
to its proper place in the orbit. He could hear better on the
right side, and the facial paralysis was scarcely perceptible.
He eat and slept well. On the 13th he could distinguish
objects held before him. The pupil, however, remained
dilated, and the iris motionless under the stimulus of light.
In about a week later the intolerance of light passed off, and
he was able to discern objects at a distance pretty clearly, but
not near objects. He could not see to read, nor make out
the hands and figures of a watch. On looking, however,
through a small hole in a card, he was able to see much
better, and could read with a little dif&culty, and ascertain
the time on the face of a watch. The ligature came away on
the 23d day. p.s. — The patient was discharged from the
hospital at the end of July. His vision was at that time
much improved. The pupil was less dilated, but still fixed.
The history of the above case clearly shows, that a severe
injury of the head had been the occasion of the formation
of an aneurism of the ophthalmic artery. The bleeding
from the ear, the subsequent discharge of serum, and
total deafness of the right ear, and paralysis of the
parts supplied by the portio aura, indicated some serious
injury to the base of the skull, and it seems probable that
the petrous portion of the temporal bone was fractured, and
that by the extension of the fracture to the optic foramen
the ophthalmic artery had been wounded by a splinter or
detached fragment of bone. There was no indication, how-
ever, of an aneurism having formed until upwards of five
weeks after the accident. Its progress was then slow, and
vision was not aflfected until nearly a month after the first
appearance of anything wrong in the orbit, and was only
slightly impaired before the operation.
I was unwilling to place a ligature upon the carotid, which
in a person of feeble health and weak power was not unlikely
THE OPHTHALMIC ARTERY. 225
to produce cerebral mischief, without an urgent necessity
for the operation ; but the previous loss of the left eye ren-
dered the preservation of the right of greater consequence.
I watched the case, therefore, with anxiety from day to day,
having resolved to tie the carotid artery immediately that
vision was seriously threatened; and having performed the
operation, apparently in good time to save the eye, I was
greatly mortified to find sight entirely gone on the second
day afterwards. This occurrence, and the recovery of sight
in a short time, are circumstances of much interest in the
history of the case. The temporary loss of vision must be
ascribed to changes consequent on defective nutrition, from
the arrest of the circulation through the carotid artery, the
aneurismal tumour interfering probably with the supply of
blood to the eyeball from collateral sources. But as the
proptosis subsided, and the circulation became reestablished,
the eye recovered its nutrition, the cornea became trans-
parent, and sight returned. The remarkable dilatation of
the pupil, which continued' after the recovery of vision,
cannot, I think, be referred to the same cause. It seems
most likely to be due to the aneurism pressing on or
stretching the ciliary nerves, and destroying their func-
tions, as respects the motions of the iris, producing, in
fact, mydriasis.
This case clearly establishes the great danger to vision
caused by a traumatic aneurism of the ophthalmic artery,
from pressure on or traction of the optic nerve, and the
ciliary nerves. It also shows, that to avoid these sources
of danger, as well as to prevent the risk of the eye being
injured by impeded nutrition after operation, a ligature
should be applied to the common carotid artery at an
early period, or soon after the detection of the pulsating pro-
jection of the eye-ball.
In 1884, I witnessed, at the London Hospital, a case of
a similar nature to the one just related. A youth sustained
a fall which produced concussion, attended with proptosis,
dilated pupil, and loss of vision of the right eye. The
prominence of the eye-ball increased, and at the end of a
xxxvii. 15
226 ANEURISM OF THE OPHTHALMIC ARTEBT.
montli pulsation was detected. During a fit of coughing,
violent arterial hemorrhage occurred from the nose, when
Mr. Scott, who was at hand, instantly tied the right com-
mon carotid artery. The proptosis subsided, but vision re-
mained permanently lost. Mr. Busk, in a brief notice of this
case, justly remarks, "the protrusion of the globe imme-
diately after the accident, without symptoms of cerebral
compression, proved that it arose from extravasation of
blood within the orbit, and the further continued protrusion
rendered it probable that the aperture in the vessel from
which the blood escaped had not closed.
These two cases, and the interesting one related by Mr.
Busk, in the ' Society^s Transactions * (vol. 22), are, I
believe, the only examples of aneurism of the ophthalmic
artery, consequent on an injury of the head, on record. In
Mr. BusVs case, it appears that a seaman was rendered
insensible by a severe blow, which was followed by bleeding
from the right ear and deafness, with paralysis of the left
side of the face, and immobility of the left eye, with dilated
pupil. Suppuration of the cornea ensued, and ended in an
opaque cicatrix of its lower half. About seven months after
the accident, Mr, Busk detected a small pulsating tumour
in the left orbit, and tied the left carotjd artery. The
patient recovered, with vision through the upper part of the
cornea, but with a fixed pupil. The proptosis appears to
have been but slight, and after the discovery of pulsation,
the carotid artery was tied without delay.
•jjii ;^*i. f
ENGLISH STATISTICS
OF
HOOPING-COUGH.
BY
EDWARD SMITH, M.D., LL.B., Lond. Univ., &c.,
HONORARY SECRETARY OF THE MEDICAL SOCIETY OF LONDON.
COMMUNICATED iTir
H. BENCE JONES, M. D.
Received June 26th.— Read June 27th, 1854.
Etiology of Hooping-Cough.
In 1851^ I published a series of papers in the ' Medical
Times/ on the Etiology of Phthisis, chiefly prepared from
returns which had been made to the General Register Office,
but which have not been issued. I purpose now to solicit
attention to similar statistical details in reference to another
and less important pectoral affection, with a view to a more
extended analysis than can be inserted in systematic works
written upon that disease. I am not ignorant of such
valuable summaries as have been given by Dr. West in his
very excellent work on ^Diseases of Children/ and more
recently (since this paper was written) by my talented friend
Dr. Gibb ; neither am I prepared to affirm that professional
opinion on this subject is in any way inaccurate ; but since
much that is mysterious still clings around the origin of
hooping-cough, and since the disease is, at the present time,
very fatal, it seems not inopportune to oflfer such further ob-
servations as the present state of science will permit. As
accuracy should be an essential element in all statistics, and
as mere numbers of cases, without any datum from which
228 ENGLISH STATISTICS
to calculate their true value, is of little or no avail, I shall
pursue my former course, and restrict my investigations to
the returns published by the Registrar-General. I do not
refer to the results of personal experience, or even to those
of any public institution, no matter how large either may
be, since, if we were prepared to grant that such returns
could be as accurate as those obtained by an institution ex-
clusively devoted to mortality statistics, they must be on a
most contracted scale, and lack that great basis of compa-
rison — the proportion to the population.
As a preliminary remark, I may observe that, whilst this
age is remarkable for the cultivation of medical statistics,
we are still, de facto, restricted to a consideration of fatal
cases only, and therefore remain wholly ignorant as to the
precise prevalence of any affection. This observation, it is
true, varies in value according to the nature of the disease
under review; for if that disease be necessarily fatal, a
knowledge of its mortality will give its real prevalence;
but, on the other hand, if the given disease be but rarely
mortal, so in the like proportion will the results of the
mortality tables be of little avail. This is pre-eminently
the case in the disease now under consideration ; for if we
may rely in any degree upon the results of personal expe-
rience, the fatal bear scarcely any proportion to the
recovered cases ; and, further, when death occurs, it is due
rather to the complications of the disease than to the dis-
ease itself. Again, mortality tables afford no information
upon many associated points of inquiry — as, for example,
the duration of the disease, and the nature and frequency
of its complications. The influence of age, sex, and season
is, for the same reason, but imperfectly shadowed forth ; for
if we aver otherwise, we must assume that, whatever may
be the proportions which these influences bear in mortal
cases, they necessarily exercise the same, in the same ratio,
in recovered cases. This cannot but be unsatisfactory to
every inquirer, and should excite the profession, as a body,
to seek a removal of the evil ; but until an institution is
established for the collection of vital statistics on similar
OF HOOPING-OOUGH. 239
priliciples to those of the General Register Offioe^ in refer-
ence to mortality statistics^ or until some combined and
intelligent efforts are put forth by all our medical bodies^
for the like purpose^ the efforts of individuals will be made
in vain.
The following summary of our available information is
true of hooping^ooughy and almost equally true of every
other disease, viz.^ that the frequency of its attack, and the
period of its duration, is really unknown ; and that the in-
fluence of age, sex, and season, is uncertainly indicated;
whilst the number of the fatal cases of the disease and its
complications, combined with the age, sex, and the season
at and in which the deaths occurred is known with almost
sufficient certainty. I shall, therefore, limit this communi-
cation to a consideration of the mortality statistics of
Pertussis.
Frequency,
As the disease is for the most part not futal, one is often-
times struck with the reports of deaths returned in the
London district, as from 60 to 80 per week in the winter
and spring months, and so many as 36 per week throughout
the year, on an average of 10 years past. The true im-
portance of this amount of mortality is not perceived by the
mere repetition of the numbers, but rather when it is con-
trasted with the mortality from some other diseases. Thus,
in the same registration district, during the 10 years from
1844 to 1853, both inclusive, of the 99 diseases which the
Registrar-General has selected, under which to arrange the
general mortality, hooping-cough occupies no lower a rank
than the 7th place from the highest. The only affections
of the chest (a class of affections with which it may be
associated) which have a higher mortality, are phthisis,
pneumonia, and bronchitis, in their order ; of members of
the zymotic class (with which it is also connected), only
typhus and scarlatina exceed it ; and lastly, of diseases of
the nervous system (with which it again has a correspond-
ence), convulsions alone have a higher mortality.
280
ENGLISH STATISTICS
Thus, of the 99 diseases, or classes of diseases referred to^
the following alone have a higher mortality, vis., phthisis^
pneumonia, bronchitis, typhus, convulsions, and scarlatina,
in their order. It is a fact worthy of prominence, that the
mortality from disease of the heart, hydrocephalus, apoplexy,
measles, and smallpox, each in its order, is less than that of
hooping-cough. This is not in accordance with popular
belief, whether in its relation to some of the affections re-
ferred to, or to others which are known to be deadly, but
which, nevertheless, have so slight a mortality as to rank
only after the last in the list just mentioned.
Table I.
Mortality from selected diseases in the London district
during the ten years from 1844 to 1858, both inclusive.
Phthisis .
• •
68-204.
Pneumonia .
• •
36*494
Bronchitis
• • •
32146
Typhus
Convulsions
• •
• • •
23-107
21-531
Scarlatina
• •
20-444
HOOPING-COUGH
• •
18-666
Disease of the Heart .
• •
17-647
Hydrocephalus .
Apoplexy
Measles .
• • •
• •
•
15-977
12-629
11-627
Smallpox . .
Total from all causes
• «
• •
9-007
. 553-694
The like relative importance of hooping-cough is observed
when the state of England and Wales is examined ; for if
we take the last returns published, viz., those of 1847, we
find that only one additional disease takes precedence of it,
viz., diarrhoea, and then the more usual diseases are phthi-
sis, typhus, convulsions, pneumonia, bronchitis, scarlatina,
and diarrhoea, in their order. There is, however, some dis-
crepancy when we analyse the great divisions into which
OF HOOPING-COUGH. 231
England is divided^ for there we discover that in the eastern
and York divisions^ there are only three or four more fatal dis-
eases ; whilst on the other hand^ in the south-western, there
are no less than sixteen diseases which to a greater or less ex-
tent take precedence. As it may be of interest to notice
the diversity in the relative mortality from various diseases
in the great divisions of England, I have prepared the fol-
lowing Table :
232
KN0U8U STATISTICS
2
n
00
Welsii.
No. U.
Phthisis 3629
Convul. 2524
Typhus 1966
SmallpxlOOS
Pneum. 888
Dropsy 868
Bronch. 672
ScarUti. 479
Measles 547
Asthma 455
Paralysis 416
Northern.
No. 10.
Phthisis 2649
Scarlati. 2012
Typhus 1304
Pneum. 973
Convul. 959
Dropsy 718
Bronch. 673
Hydroce. 526
Diarrh. 519
Heart 486
ParalysU 433
*<•
York.
No. 9.
PhthUis 5228
Convul. 3896
Typhus 2900
Scarlati. 2279
Pneum. 2221
fH
North Western.
No. 8.
Typhus 9076
PhthisU 9044
Convul 5399
Diarrh. 3868
Pneum. 3464
Scarlati. 3439
Bronch. 2979
Measles 2121
Dysent. 1632
•
00
o
<o
North Midland.
No. 7.
Phthisis 3505
Convul. 2187
Typhus 1664
Pneum. 1428
Dropsy 798
Bronch. 654
Measles) 645
Diarrh. 550
Heart 510
Scarlati. 480
<o
»<»
-*
West Midland.
No. 6.
Phthisis 5976
Typhus 3388
Pneum. 3307
Convul. 2506
Scarlati. 2493
Bronch. 1929
Dropsy 1608
DUrrh. 1480
Measles 1143
Heart 1065
esi
o
^4
South Western.
No. 5.
Phthisis 4743
Pneum. 22301
Typhus 1662
Dropsy 1634
Bronch. 1212
Convul. 1109
Apoplexy 946
Heart 919
Paralysis 748
Hydroce. 577
Diarrh. 568
Measles 568
Cancer 542
Inflam. 488
Asthma 431
EnteritU 372
CO
<o
CO
Eastern.
No. 4.
PhthisU 3457
Pneum. 1286
Typhus 1262
381 806
South Midland.
No. 3.
Phthisis 4569
Typhus 2030
Pneum. 1529
Convul. 1027
Dropsy 919
Bronch. 779
Apoplexy 597
Heart 553
Diarrh. 546
Scarlat. 542
Paralysis 488
South Eastern.
No. 2.
Phthisis 4507'
Typhus 1884.
Pneum. 1831,
Convul. 1442
Bronch. 1300
! Dropsy 1161
1
i
©
o
©
• M
2 3
3 o
OF HOOFINO-COUOH. 3SS
It must be remembered^ when studying these tables^ that
whilst No. I is obtained from an average of 10 years, and
may therefore express the trnth, No. II represents but one
year, and may be, in some of its parts, only an approxima-
tion to the truth. Moreover, the numbers now referred to,
demonstrate only the actual deaths which have occurred,
and not the true ratio of mortality ; and it must ever be
borne in mind, that the absolute mortality and the ratio of
mortality are not convertible terms. The ratio of mor-
tality can only be determined by selecting some basis for a
common computation, and then computing each one sepa-
rately on that basis. The basis most commonly selected
of late years, is that of the population at the ages at which
the deaths took place. This I shall use when considering
the influence of age over the mortality from hooping-
cough. The older basis of computation (or that adopted
before the returns of the census were so minute and accn*
rate as at the present time) was the total mortality in given
districts ; but this is of but little value, for it is a matter of
common belief that the relative prevalence of many diseases,
as of phthisis and typhus, for example, has varied much
during the last fifty years. On this basis, the mortality
from hooping-cough was to the total mortality in London,
during the 10 years (1844 to 1858), as 1 to 29-6. This
fact may be used as an excellent illustration of the import-
ance of preparing statistics from a series of years, rather
than from any one year; and also of taking a wide area over
which they may range. Thus, in 1847, the proportion in
all England and Wales, was as 1 to 45*7 ; and in London, in
that year, instead of being as 1 to 29*6, it was as 1 to 37'.
Great variation was observed in the several divisions, rang-
ing from 1 to 94-8, up to 1 to 28- 1. Thus, eastern 28-1 ;
south-eastern, 32-8; York, 35 -5; London, 37'; north-
western, 49*2 ; west midland, 49*4 ; northern, 58*8 ; south-
midland, 68*4 ; Welsh, 72' ; and south-western, 94*8.
Recurring to the London statistics for the 10 years above
mentioned, we notice that the mortality varied greatly
throughout the series, and was the greatest in 1853 (50 per
234 ENGLISH STATISTICS
week)j and 1849 (46 per week), whilst it was the least in 1844
(25 per week) ; the average of the 10 years being, as above
mentioned, 36 per week. In explanation of this fact it may
be stated, that the two former years were also remarkable
for their general mortality, and that cholera was epidemic
in 1849; for a common belief prevails to the effect, that the
degree of mortality of any disease may be influenced by the
healthiness or otherwise of a season regarded as a whole.
That these two facts do not run parallel in this instance, may
be inferred from the following facts. The general mortality
was far greater, and yet the mortality from hooping-cough
was much less in 1849 than in 1853. The year 1847 had
even a higher ratio of mortality than 1858, and yet the
weekly deaths from hooping-cough were only 80*7 in 1847 to
50 in 1858. In 1849 and 1853, the deaths from allied
nervous, pectoral, and zymotic diseases, separately^ weie
increased with the increase of the general mortality, but not
by any means in the proportion in which the mortality firoia
hooping-cough was increased ; whilst on the other hand, in
1847, the mortality from hooping-cough was very greatly
reduced, and yet that from influenza was increased tenfold ;
and from nearly all other members of the zymotic class, with
pectoral diseases, was doubled. The mortality from nervous
diseases was also then increased. The year 1844, which was
so exceptional in reference to the diminished mortality from
hooping cough, was not in like manner exceptional in relation
to the general mortality; for whilst the general mortality was
low, it was yet higher than other years in the series, in which
hooping-cough was more fatal.
Thus if is probable, that the mortality from hooping-cough
bears no exact analogy to that from all causes, nor to that
from the most closely allied classes of diseases. It is
needful to proceed from the examination of generals to
particulars, such as age, sex, and season, in order to dis-
cover the special circumstances which exert so important an
influence over this disease.
OP HOOPING-COUGH. 235
The Influence of Age,
The influence of age is well marked^ and in accordance
with common belief. The latest statistics^ on a large
scale^ are those of 1849^ for England and Wales, which give
the mortality from each disease at yarious ages. Before
using these returns, it is necessary to determine the ratio of
mortality as estimated from the population living at the
various ages during that year. We have the returns of the
census for 1841, and the proper correction for the increase
of population for the six years is the addition to the census
of somewhat less than a ^th part. It is true that this
correction must vary with the varying increase of population
during each decennial period, and ialso that the rate of
increase on female lives, as determined by the census of
1841, viz., 1*332 per cent., has not been confirmed by the
census of 1851 ; yet, as the last decennial retrogression has
been due to temperature and pestilence, neither of which
occurrences had excited any very marked disturbing influ-
ences previous to 1847, we are, I think, justified in using
for that year the old rate of increase. Whatever rate, how-
ever, is agreed upon, the relative mortality of diseases in that
year is equally well determined. As I adopted that cor-
rection in the paper on the 'Etiology of Phthisis,' I propose
to resume it here. The ratio of mortality from hooping*
cough to the whole population, at all ages^ when calculated
on the above basis, is as 1 to 1814 ; whilst, for comparison,
that of phthisis is 1 to 324; and of pneumonia, the second
disease in point of mortality, 1 to 737. The following
table exhibits the absolute mortality, with its ratio to the
population at various ages, as observed in England and
Wales in 1847 :
2M
ENGLISH 8TATIITIC8
Table III.
Ace.
Deotlia in Esf •
ItnA and Wain
iftir.
ParCentafe pio-
wkole Daatkf
9S60.
BatioorMoriaUty
to the PoDola-
lioB at Taridoa
Agea.
AUagei.
9260
1 in 1814
Under kL I jetr
1 to2
3746
2546
40-4
27-4
M 123
H 182
Under st 2 jtun
6292
67-8
13-8
07-7
04-7
2to3
3^4
4 H 5
1284
720
437
n 367
f, 614
H Ml
Under Kt. 5 yean
8733
94*1
ff 260
5 to 10
10 „ 15
16 „ 20
Upwards to 90
Unknown
487
20
6
12
2
M 4222
9260
From the above table we leam^ that more than two
fifths of the whole deaths occurred under 1 year of age ;
more than two thirds under 3 years of age, and nearly
the whole^ that is, nineteen twentieths, under 5 years.
The chief feature in reference to the true ratio of mor-
tality is the fearfiil prevalence and fatality of the disease
when attacking infants under 1 year of age. This is no
less than 1 to 123 living^ a mortality considerably greater
than that of phthisis^ and beyond that of any other
disease except those comprehended under the general terms
convulsions, pneumonia, and diarrhoea, in their order. We
may safely affirm, that hooping-cough (with its complications)
is the most fatal of all diseases during the first 12 months
of life. From this period it progressively and gradually
declines in fatality until the commencement of the 5th year,
and after the 10th year is comparatively innocuous or
unknown. This fact being established, it would be proper
to analyse the circumstances which attend upon the earliest
months of existence, with a view to isolate those which have
OF HOOPINQ-COUGH. 287
an especial reference to the production of this disease^ but I
am not aware of any data on which we can proceed, except
such as exercise an influence over the general mortality at
that early period, and especially such as tend to produce con-
vulsions, or other fatal derangements of the nervous system.
There can be no doubt of the fact, that the high degree of
sensibility to impression which attends upon infancy, plays a
most important part in this, as in other diseases, but that it
does not simply act by adding intensity to the effects
accruing from changes of temperature, may be inferred from
the (probably) equal prevalence of the affection amongst all
classes of the community ; and in like manner it may be
inferred, that it does not act by the ordinary zymotic influences
only, since it alone, of all zymotic diseases, nestles itself
habitually in the infantas cradle.
The Influence of Sex.
The influence of sex over mortality is in general rather the
indirect one of the circumstances in which each sex is espe-
cially placed, than the direct one of any peculiarity of orgai-
nization. (Diseases of the sexual organs are of course ex-
cluded from this statement.) But few diseases are known
to have any universal preference for the female over the
male sex, although most diseases have their nervous element
somewhat more developed in the former than in the latter.
This latter has usually been attributed to the higher sensi-
bility or delicacy of organization which experience has ascribed
to the female sex ; and since we cannot doubt that this con-
dition of system does obtain, it would not seem an unreason-
able inference if we were to infer that any affection which
has its essential seat in deranged nervous function, may
directly prevail in the former sex. Yet, as suggested to me
by my friend Dr. Sibson, such an inference is directly nega*-
tived by the palpable fact that convulsions (in the somewhat
confused form recorded by the registrar-general) are not only
more frequent in males at all ages, but in infants under
1 year. It is difficult to reconcile this fact with what would
238 ENGLISH STATISTICS
otherwise appear to be a legitimate deduction ; and although
at all times ready to give the preference to fact over theory,
we cannot but believe that some circumstances exist, as yet
unknown to us, which would greatly modify the influence of
the fact just mentioned. Whether this is associated at all
with the distinction between mortality and prevalence to
which I have before referred, I cannot teU ; but it is quite
within legitimate conception, that a disease may prevail in
one sex, and yet be even more mortal in the other sex. In
convulsions, for example, it does not follow, that because the
greater mortality has been undoubtedly observed in the male
sex, that therefore the true ratio of the prevalence in num-
bers, of the disease, attaches to that sex, for it is one thing
to have a disease, and another to die from it. Morpover^ as
more males than females are born, it would demand more
deaths of the former than of the latter, in order to make
an even ratio of mortality. Further, if we may justly admit,
that there is greater sensibility to impression in the female^
we may with equal truth affirm, that there are greater powers
of passive endurance also; and therefore it is not inconsistent
to state, that females may be more liable to a disease than
males, and yet that the mortality may be reaUy greater in
males.
But if this reasoning may be allowed in reference to
convulsions and other nervous affections, it does not suffice
to explain the indisputable fact, that hooping-cough is much
more fatal in females than in males. The female system, in
reference to this disease, seems to have not only a theoretical
predisposition to its attack, on account of its delicacy of
organization, but a predisposition to succumb under its influ-
ence; for not only are there more females than males living
at every age, but the number of deaths and the true ratio of
mortality are greater in the female sex. This is a most
interesting fact in relation to convulsions, and other fatal
nervous diseases with which hooping-cough, in its essential
character, is unquestionably allied^ and one which for the
present appears to be inexplicable. It may be true, that
hooping-cough kills by its complications, and that these com-
OF HOOPING-COUGH.
289
plications are usually inflammatory; but that does not help
usy unless we could prove by statistical facts^ that the female
system is especially prone to the attacks, and the fatal termi-
nation of inflammation. The fact, however, remains, that
hooping-cough is more mortal in the female than in the male
sex; but there are no data to show, that the female system is
more prone to the attacks of the disease.
The following table shows the number of deaths from
hooping-cough which occurred in each sex at various ages
in England and Wales during 1847, with their respective
ratios of mortality to the population.
Table IV.
Ages.
VALES.
rXVALSS.
Deaths in Eng-
land and Wales.
18*7.
1
Proportion to
the Population.
1847.
Proportion to
the Population.
1847.
Deaths in Eng-
land and Wales.
1847.
f All ages . . .
4126
1 in 2044
1 in 1717
5134
Under set. 1 year
1 to 2 years
2 „ 3
3 „ 4
4 „ 6
1767
1092
567
318
169
H 143
„ 212
» 414
„ 689
„ 1297.
,f 119
„ 159
,, 330
f» 554
„ 807
1979
1454
717
402
268
Under set. 5 years
3913
.. 288
„ 237
4820
5 to 10
10 ,, 15
15 „ 20
Upward
Unknown
202
4
3
4
285
16
3
8
2
4126
5134
The above table proves, not only that at every period of
life the true ratio of mortality is higher in females than in
males, but the yet more interesting fact, that this pre-
ponderance increases as life progresses. Thus, whilst under
1 year of age, the excess in the ratio of mortality amongst
females is one sixth, it is less than one third in the fifth
year of existence, and was reduced to one fourth in the second
year, and one fifth in the succeeding intervals. It is unsa-
240 BNOLT8H STATISTICS
tisfactory to pursue the comparison at later periods of life, on
account of the smallness of the numbers to be contrasted, but
so far as this is of value, it proves that this preponderance is
maintained, and even increased at puberty, and for an inde-
finite period beyond that sera. This curious fact sustains, in
a degree, the theory above mentioned, vis,, the predisposition
arising from organization, since we may assume that the
peculiarities of the female organization are not so distin-
guishingly developed within the first year as in subsequent
periods of life.
The Influence of Season.
We have hitherto been unsuccessful in all attempts to
determine what element of the series constituting atmos-
pheric phenomena, has had permanent influence over any
disease, although, at the same time, we know well that the
atmosphere, as a whole, or by some of its component parts
and properties, does exert an important influence to this
end. Electricity, winds, vapour, barometric pressure, and
temperature, have each been investigated, and in all cases
with some success ; but with the exception of the latter, the
published returns for series of years, either from want of
uniformity in design, or occasional omissions and alterations,
are not available. Temperature is therefore the only ele-
ment which we shall consider apart from the others consti-
tuting the season.
The average temperature of the 10 years selected, 1844
to 1853, was 49*3°, whilst that of the two exceptional years
of great mortality from hooping-cough, viz., 1849 and 1853,
was 49'9^ and 47*7° respectively. The year 1853 had a
lower temperature than any in the series, except 1845,
which was only ith of a degree colder. It was otherwise,
however, with 1849, for six of the ten years had a lower
temperature than that year. Thus, although the first men-
tioned year, that of 1853, was decidedly characterised by a
low temperature, and experienced the greatest mortality
from hooping-cough, and so -far would connect cold and
OF HOOFINO-COUGH. 241
hooping-cough together, it must be remarked, that the yet
colder year of 1845 had only two thirds of the number of
deaths from that disease ; and, on the contrary, the year 1849,
which had so great a mortality from hooping-cough, was a
little warmer than the average of years. Considering the
year as a whole, therefore, we do not trace the connexion
between excess of cold and excess of mortality from hooping-
cough.
In order to study the relation between temperature and
this disease, we must examine, not only the exception, but
the rule, and enquire what is the ordinary occurrence at the
various seasons of the year. I have, therefore, examined
these two points in each quarter of the seven years, 1847 to
1853, both inclusive, and have ascertained that the greatest
mortality occurred five times in the 1st, and once in the
2d and 4th quarters, and that the least mortality took place
five times in the 3d, and twice in the 4th quarters. This
proves that the winter is the most obnoxious, and the summer
the least obnoxious to this disease. But it may be objected
that the division into quarters is artificial, and that as the
seasons run insensibly into each other, and yet during the
year exhibit two opposite characters, it is more reasonable
to convert the 1st and 4th quarters, either of the same, or
better still, of consecutive years, and call them winter, and
the 2d and 3d quarters and call them summer. Adopting
this more natural division of seasons, I have found that the
greatest mortality in the 7 years, was 5 times in the winter,
both of the same and of consecutive years, and the least
mortality 5 times in the summer. This exhibits a remark-
able correspondence with the results of the computation by
quarters, and clearly demonstrates the influence which tem-
perature exerts over this disease.
The following Tables illustrate the above remarks.
xxxvii. 16
KNOLISR STATIffTIOR
Tabi-bs V nnd VI.
Iloorl>[««lh in Ion-
tilil;, >IJ In tU
«D» JOU.
•mill! Ian.
1853
M.
M.
u.
«h.
aBmmtT,] Winter.
Sbouiu.
Winur,
t?tt
18^3
I2H3
101 s
1852-3
1832
IG6
M
m
710
855
1SS2
710
82a
1B51-2
IBM
^^4
m
1034
1067
laai
1094
1205
1850-1
leso
141
421
BG6
isao
708
715
1B49-50
184B
m
7.1£
m
1167
97B
1849
1167
1377
1848-9
184S
11-
H'
789
B4G
1848
789
Ron
1847-8
1817
iU
in
^38
m
630
970
1847
A complete analysis of the influence of temperature de-
mands a yet further restriction of the period over which the
average shall be carried. The returns of the Registrar-
General would enable us to reduce the average of the mor-
tality to weeks, and of temperature to days, but since in but
few, if any, instances do the atmospheric conditions of a week
produce immediate death, it would be needless to so far
limit our attention. Persons may reasonably differ in
opinion as to the length of time which may usually elapse
between any atmospheric change and the fatal results, and
therefore, as to whether the lowest analysis should be that
of 2, 3, or 4 weeks. As the selections must be arbitrary,
but yet so lar founded on observation, I think that
monthly periods would probably exclude mere occasional
influences, and connect together, by an average, the cause
and its effect. I have adopted this plan, and have deduced
the weekly average both of mortality and temperature from
the totals of each concluding month in the years 1847 to
1853, both inclusive.
OF HOOPINO-COUGH.
248
PQ
<
Q
t
.O
is
1.^
^
g
•
•3
a
1
January
February
March
April
May
June
July
August
September
October
November
December
•
00
6,
CO ^^ ^ '^ CO Cfi ^
'**<C0C0'r!'»«»O<O<O»«»OiOC0
o
O>a0«O"^?0rH©rHift«b4|«»lH
eo»ft«0i>.«o«0'<«j«ecc^e0'^«o
•
00
1—4
•
C^ «0 1-4 ^ CO !>. C^ 0» "tl* 1-* !>.
• ••••••••••
-^i-4©Oi-4»ft»oc^t^ao©«o
•
tO O kA <p -^ «p *^
»facO'^^eoc»l-H^c^^c^c^c^
1851.
•
f^ t^ »ei CO r^ -^ Oi ifi
•
1
a
»ft Tj< ci CI i^* "^j* ^* OJ OD »o
QO'^'Tt•Cico»b»ftaoaor^<w^^
'^oi>.o«0'**<eoci-H-HC»ic^
1850.
1
COO»0>GOC^eO eit>»rH 0»
e^eoo)t^o»©dF- itOGOtook
cO'*eO'^rt«toto«o«rt'i*T»<co
•
o
CI CI CI "^ t;»«p CI
©-^l^t^^^tOtOWrHiOOIibl?*
eoeocoeocodciciciciciift
•
00
a
©cicicjwicicii^'^i'-a)
t
a
»ft «p d -^ d CI <p ^*
©©«bQOrHC^^•^b^*c^aoc^
tOOl-^-in^OiOCOCOCICIrHCI
•
QO
"^
00
•
a
u
51
^CI»OO>»O»O00 eO-HCIO»
• •••••• ••••
'<fcocit^O»0>'-*ir^r>.CleO'^
•
1
lA ip d r*«poT(<»p «c
c4to«bQO«oaodoci^«6)0)i^
cocicieocociciciciciciTf
.
GO
•
1
•^-^ft^CI «OCleOCI»OQO'*
• ••• «••••••
'V»oo4eo»oi>.'<fci»ftci«oci
coco^*oo»oco;o»otO'^-^
•
i
'^l^c^»bcOl-400^*6>6»^*^*
^"<tC0eOCOCIf-ii-4rHrHCI"««f
•
§
>3
bSjj • • • •« Base
244 ENGLISH STATISTICS
The same facts are also represented in the diagram No. I^
in order that the contrast of temperature and mortality may
be more quickly appreciated.
The foregoing Table and Diagram show^ that the mor-
tality and temperature are in the inverse ratio to each other^
and that the former proceeds in waves from about August^
when it is at its minimum^ to about Aprils when it is at its
maximum^ returning to its minimum about the following
August^ and thus continuing in even waves of increase and
decrease^ with remarkable regularity, from year to year. The
maximum and minimum mouths occasionally vary. Thus, the
former, instead of being April, may be March, and in one
instance, it was the preceding December ; whilst the latter^
instead of being August, may be July or September, and in
one instance, was even November. This degree of varia-
tion, however, in no sense invalidates the rule which has just
been laid down. In reference to temperature, the Diagram
proves that the mark of its maximum is not that of the
minimum of mortality, but the one which immediately pre-
cedes it j and so, in like manner, with the minimum of
temperature and the maximum of mortality. This rule is
also, like other rules, liable to exception; but when such
exceptions occur, it will usually be found that the tempera-
ture, or the mortality, has remained at nearly the same
point during two or three months. In such instances, it
manifestly gives a false importance to one particular month
over its neighbour, if it be denominated the minimum
month, because it had one, two, or three degrees less tem-
perature. Such is the relation between mortality and
temperature; and after making every allowance for excep-
tional cases, we cannot but be struck with the regular and
almost constant apposition upon the Diagram of the two
lines of temperature aad mortality.
The waves of the greatest intensity in the series of years
referred to (1847 to 1853), occurred at intervals of two
years, and were succeeded by a marked rapid and extreme
subsidence in mortality during the summer and early
autumn months, and did not again approach to the same
OF HOOPING-COUGH. 24&
intensity during the succeeding years. Thus, in 1849,
1851, and 1853, the highest average weekly mortality in
one month, was 76'6, 74i'4i, and 74*5, respectively, whilst
in the alternate years, 1818, 1850, and 1852, the like
highest average was only 47*6, 51*2, and 52*. Jn the latter
part of the former years, however, there was not that uni-
formity of opposition of the lines of mortality and tempera-
ture which constitutes the rule, but, on the contrary, a dis-
position was manifested to pursue a parallel course. These
facts may tend to prove, that a severe outbreak of the dis-
ease is followed by diminished intensity of mortality, and
that, to a certain degree, in spite of the action of causes
which, under other circumstances, would have heightened
the mortality. This is an interesting feature, and one
which it would be worth the trouble to work out through a
much larger series of years, could we obtain the necessary
statistical returns. It, however, probably corresponds with
some other zymotic diseases. Another circumstance of
interest to be gathered from the Diagram is this, that at
the close of each alternate year of accession, the intensity of
mortality seemed rather to move in advance than in the
year of the subsidence of the temperature, in opposition to
the fact just noticed in relation to the years of intensity ;
for, in November of the years 1848, 1850, and 1852, the
mortality suddenly increased, whilst the temperature yet
remained at a tolerable height, viz., 45^.
The intensity of mortality usually advances and recedes
by slow and stealthy steps, but in many instances, it ap-
pears to leap suddenly in another direction, and it is not
difficult to draw a line which may be considered the boun^
dary line between low and high mortality. This lay be-
tween 45° and 48°, for it was only as the summer tempera-
ture descended to that point that the mortality assumed a
decided average tendency to increase.
From all the foregoing observations, I think it is clear
that mortality of hooping-cough attends diminished tempe*
rature with considerable precision, and so far may have a
point of correspondence with other seasonal affections ; but
246 ENGLISH STATISTICS
there is one point in which it differs from others^ riz; that
it is not increased in intensity by any intensity of the oppo-
site season^ or that of summer. Excessively high tempera-
ture, so far from having given rise to increase of mortality^
was directly^the reverse^ and when the wave of minimum
mortality occurred so late as the October of 1851, it was
because the average weekly temperature of that month was
54^ — a temperature higher than that of the same month in
any of the other years in the series.
In order the more certainly to establish the position just
laid down, I considered that indirect as well as direct evi-
dence should be adduced. I have, therefore, prepared
Table IX and Diagram II, with a view to show the absolute
and relative bearings of temperature with the general mor-
tality, and the three classes of disease with which hooping-
cough is associated, viz., the zymotic, the pectoral (including
phthisis), and the nervous ; and also with a further view of
ascertaining what correspondence in these relations exists
between hooping-cough, and any or all of the three classes
of diseases referred to. The table has been compiled by
abstracting the weekly returns of deaths from the weekly
reports, and adding the numbers together by months, and
then dividing the result by the number of weeks, in order
to obtain the weekly average per month. The Diagram is
thus one of interest from the tangible nature of the extensive
information which it readily affords. The relations of
hooping-cough and temperature having been given, I need
not again refer to them, but in describing those of the other
lines of disease, I shall, throughout, have in view the inten-
tion of further illustrating this relation.
First, in reference to the line of general mortality. It is
quite clear that the general direction of this line is directly
opposed to that of temperature — the highest mortality oc-
curring at the season of lowest temperature, or winter, and
the lowest mortality at the period of highest temperature, or
summer. The highest mortality is observed about January,
but varying from December to March, and in 1852, was so late
as May, whilst the lowest mortality occurs almost invariably
OF HOOPING-COUGH. 247
in June and July. In the cholera year of 1849^ and in
that alone^ the lowest mortality was observed so late as
November — that is, after the epidemic had subsided — and
may naturally be attributed to the lack of subjects of fatal
disease. The most healthy period of the year is from April
to November, except in such years as experience the recur-
rence of fatal epidemic diseases. It shoflld also be remarked,
that^ for the most part, the most fatal seasons in a series of
years, are such as have the lowest temperature, as was the
case in the winters of 1847-8 and 1852-3; whilst, on the
other hand, the periods which experienced the lowest mor-
tality in a series of years, as 1848 and 1850, were marked
with the highest degree of temperature. The months of
highest temperature and lowest mortality are not usually
the same, but, as in 1849, the latter is a month later than
the former. Thus it was particularly the case when the
temperature had somewhat suddenly increased; for when
the temperature throughout the winter had remained some-
what high and stationary for some months, as in 1850-1,
or when it had increased considerably in March and April,
as in 1847, the monthly lowest mortality was in advance of
that of highest temperature. In the latter case, it would
seem that the long-continued high temperature became, be-
yond a certain point, a cause of mortality. On contrasting
this statement respecting the general mortality with that of
hooping-cough, several disparities will be observed sufQcient
to show that the cause of mortality from the latter disease
is not identical with that of the general mortality.
In abstracting the returns for the three great classes of
disease, I have comprehended the whole of each class, on
the ground that, however diverse one number may be from
another, they have essential points of resemblance; and
also, because I could not venture to aflBrm that any one
which I might wish to exclude had less connexion than any
other with hooping-cough. The object is attained if they
show, in general terms, the relation which they bear to
hooping-cough.
The zymotic class, is remarkable from the opposition in
248 ENGLISH STATISTICS
its lines with those of hooping-cough^ since there are un-
doubtedly essential bonds of union between them. This
opposition is the more remarkable in that hooping-cough is
included in the litie of zymotic disease.
In the zymotic class the lowest mortality is observed to
correspond with the low temperatui'e, and therefore with the
beginning and the «close of the year ; whilst its highest
mortality is observed in August or September, and therefore
corresponds with the period of considerable, but not of the
highest temperature. In no instance does its acme pre-
cede that of temperature, but it either corresponds with it^
as in the cholera epidemic of 1849, or, as is more customary,
immediately succeeds it. Its progress appears to be in
cycles, having its origin or lowest point immediately after
a severe outbreak of the disease, and thence remaining
stationary for a period, but ultimately increasing in mor-
tality by slow increments, until it again attains its maxi-
mum. There has been, as yet, no such yearly zymotic
mortality since 1849, as was observed in the years immedi-
ately preceding 1849, but there has been a gradual incre-
ment since 1850. In all these various points, this great
class differs from hooping-cough, and in its essential cha-
racter is directly opposed to it. Indeed, there is not an
instance during the seven years in which the lines of alter-
nate increase and decrease of hooping-cough are not directly
opposed to those of the great zymotic class ; whilst, on the
contrary, in almost all cases the zymotic lines and the lines
of temperature tend to the same direction. This is a strong
argument against the essential aflBnity between mortal cases
of hooping-cough and the class under consideration. It is
therefore certain, that our deductions in respect of hooping-
cough are not weakened by any possible similarity between
it and the zymotic class of diseases.
Directly opposed to the zymotic class is that of pec-
toral affections, for the lines of this class are in opposed
waves to that of temperature, and in marked correspond-
ence with those of hooping-cough. The highest point of
mortality is almost invariably met with in January, and
OF HOOPING-COUOH. 249
corresponds accurately with that of the lowest temperature,
lu this latter respect the pectoral class differs from others^
hooping-cough included^ for its mortality keeps nearly even
pace with the temperature. This is very strikingly manifested
upon the Diagram. Its lowest mortality, too, is observed
at the very months which have the highest temperature of
the season, and thence remains nearly stationary during two
or more months, or has a gradual tendency to increase. The
months intervening between April and November, or
December, are the least infected with this class of diseases,
and in this respect, this class corresponds with the general
mortality. The only noticeable distinction to be made
between the lines of mortality from hooping-cough and
chest diseases is, that whilst both invariably take the like
direction, the former follows the latter in descending, and
precedes the latter in ascending. The great similarity be-
tween hooping-cough and chest diseases, contrasted with the
dissimilarity between the former and zymotic affections,
cannot fail to induce us to regard them as most closely
^ allied, and may almost suffice to induce us to enquire if
they are not, in their morality, the same disease. It must
not be forgotten, that hooping-cough, as such, is seldom
fatal, and that the mortality really arises from its complica-
tions ; if, therefore, we admit the evenness of the mortality
of the two diseases, it would only be affirming, that in a
great majority of the deaths from hooping-cough, the chest
complication is the cause of the death, and it would leave
the eventual nature of hooping-cough untouched.
The third great class of diseases, or the nervous, offers
but unsatisfactory evidences of its affinity to hooping-cough,
and that, perhaps, from the fact just alluded to, viz., that
whatever hooping-cough may be, it is not usually mortal.
The Diagram shows a remarkable uniformity and narrow-
ness of limit in the range of this class of disease through
each year, and through a series of years. The line scarcely,
if ever, has a greater range than 50 cases, and throughout
the whole year does not extend through one half that
amount. It can, therefore, scarcely be influenced by the
250 BNOLISH STATISTICS
change of seasons, and, conseqnently, can offer bnt little
affinity to hooping-congh, the general mortality, zymotic, or
chest affections. The highest point, little yarial as that
may be, appears to be dnring the cold season, and its lowest
during the middle months of the year. Thus, on a reriew
of the analyses of the mortality lines on the Diagram, we
may affirm that the lines of hooping-cough do not precisely
correspond with those of the general mortality ; that they
are directly opposed to those of the zymotic class; that
they are greatly in accord with those of chest diseases ; and
lastly, that they have but little evident relation with those
of nervous diseases. Thus we infer, that hooping-cough is
a disease apart from those affections, and that any deduc«
tions made from its returns, cannot be weakened by any
supposed resemblance between it and these classes of dis-
eases. Further, we may affirm that mortal cases of hoop-
ing-cough disprove any alliance between it and zymotic
disease, leaves it in doubt in reference to nervous diseases,
and offers much support to an alliance with -chest affections.
In order to exemplify the foregoing statements more •
clearly, I have compiled Table and Diagram III. These
show the weekly average of the temperature, hooping-cough,
and bronchitis, in the seven years already referred to, con-
densed into one year. By this mode, the ordinary varia-
tion is nowhere uninfluenced by temporary causes, and a
more correct notion is given of the seasonal temperature and
its influence on the mortality of the diseases in question.
The highest temperature occurred in the 28th week, and
thence the temperature gradually and progressively declined
to the end of the year, when it was at the lowest point, and
its degree was precisely that observed in the first week of
the year. Thus, the first and the last weeks of the year
have the lowest, and 28th week the highest temperature.
The progression and retrogression exhibited much uni-
formity, and from the 6th to the 11th week, the variations
were more perceptible than at any other period of the year.
The mortality from hooping-cough attained its minimum
(25 per week) in the 33d week, and continued low until the
OP HOOPINO-GOUOH. 251
47th weeki when it suddenly increased to 87 and 42 per
week, and terminated the year with 40 per week^ the pre-
cise number with which it began the year. From this
point it gradually increased until the 12th week, when it
attained its maximum, and thence gradually, but with many
variations, declined to its lowest point. In reference to it«
relations with the line of temperature, the following points
may be noted. The two lines intersected each other in the
16th and 51st weeks, and from the 19th to the 49th week
were directly opposed to each other. From the 49th to the
end of the year, and from the beginning of the year to the
17th week, the lines, generally speaking, assumed a parallel
and closely approximated, yet variable, course. There was an
interval of five weeks between the highest temperature and
the lowest mortality, but it must be mentioned, that the
2d week after the highest temperature, the mortality was
nearly at its lowest point. Thus the mortality continued to
decline for some time after the temperature began to slightly
decline. It also continued low^ not varying 5 cases per
week, so long as the temperature continued above 48°, and
thence it assumed a rapidly upward tendency.
The general parallel course between the lines observed at
the beginning of the year is no evidence that the mortality
was uninfluenced by the temperature, for at various parts the
relation was very manifest. Thus, the downward tendency
of the temperature in the 8d week, induced at the same
time an upward tendency to the mortality, and so also in
reference to the lower temperature of the 6th, 8th, and
10th weeks, for these were followed by increased mor-
tality in the 7th, 8th, 10th, 11th, and 12th weeks. The
increase of mortality, therefore, followed the diminution
of temperature at an interval of one or two weeks, but the
new tendency thus given did not subside on the instant, with
an increase of the temperature, but continued for a period
longer. Whenever, therefore, in the variations, the two lines
run a parallel course, or may be seen between the 6th and
13th weeks, the true cause of the course of mortality is
antecedent to that of temperature. The mortality never
252 ENGLISH STATISTICS
moves in advance of that of temperature, but often retains
the impetus for a time after the projectile force has been
withdrawn. Thus the general parallelism above referred
to^ directly confirms the truth of previous statements when
analysed into its weekly variations. If further illustration
were needed^ it would be afforded by the lines passing through
the 30th to the 39th week, in which the downward tendency
of mortality is continued for a time after the temperature
had ceased to increase, and in which alternate increase and
decrease resulted from variation of temperature in the two
weeks antecedent. Indeed, so universal is this rule in its
application^ that throughout the whole year the variations
may be safely explained by it. The line of temperature
below which hooping-cough runs its most mortal course^
passes through the 4S°, both in its advance and in its
retrocession.
I have selected bronchitis as a point of comparison^
on the ground established by diagram 11^ viz.^ that a
close affinity exists between the class of pectoral affections
(excluding phthisis) and mortal cases of hooping-cough; and
further, because of all pectoral affections, I was of opinion
that bronchitis was by far the most common disease. The
line of mortality from bronchitis is worthy of attention^ both
absolutely and relatively to hooping-cough. Its highest
point is in the 49th week (142 cases per week), whence it
rapidly descends to the end^of the year to a point lower
(16 cases per week) than at the commencement of the year,
and continues high until the 11th week, when it suddenly
and progressively declines to the 31st week, and is at its
minimum (27 cases per week) ; and after remaining nearly
stationary during 6 weeks, begins rapidly to ascend to the
37th week, and in 12 weeks reaches its maximum. Thus it
is essentially a winter disease, and leaves so large a portion
as the half of the year, at which its mortality does not attract
attention. The chief points of contrast between this and
hooping-cough are, that its variations attend more in-
stantaneously upon temperature, and are to a much greater
extent ; that its highest mortality occurs at other times, and
OF HOOPING-COUGH. 253
that the mortality remains stationary at and ascends under
a higher temperature, whilst its point of agreement is the
general direction of its lines with hooping-cough, and oppo-
sition to those of temperature.
The following conclusions are a few of those which may
be drawn from the foregoing communication :
1. In reference to its frequency:
In the London district the diseases which are more
fatal a^e phthisis, pneumonia, bronchitis, typhus, con-
vulsions, and scarlatina, in their order. In all England,
in 1847, diarrhoea was added to this list, and their
order varied. There was greater diversity in the great
registration divisions, both as to the precedent diseases,
and their order of mortality.
The proportion to the total mortality in London is
1 : 29-6. In aU England in 1847, 1 : 45*7, and varying
in the great divisions from 1 : 28- 1 in the eastern,
to 1 : 948 in the south-western. It is as 1 : 1824 of
the total population.
The most fatal years from 1844 to 1853, in London,
were 1849 (45 per week), and 1853 (50 per week) ;
and although both these years had high general mor-
tality, the increased mortality from hooping-cough was
not due to that circumstance.
The lowest mortality was observed in 1844 (25 per
week), and that did not correspond with the general
mortality.
The deductions in reference to hooping cough do not
correspond to the general mortality. They are directly
opposed to the zymotic class, and have little relation
to the nervous class, but exhibit a remarkable cor-
respondence with the pectoral class (excluding phthisis).
This latter fact indicates a close analogy between fatal
cases of hooping-cough and chest affections.
254 ENGLISH STATISTICS
2. In reference to age:
It is a disease essentially of the period of dentition
of the first series^ and under set. 1 year is the most
fatal of all diseases. It thus differs from all other
members of the zymotic class.
3. In reference to sex :
The mortality is more prevalent in females at every
period of life^ and this prevalence increases as life
advances; but it does not thence follow^ that the
disease itself is more prevalent in that sex. But if it
be so, it is probably due to the susceptibility to im-
pression^ and the power of passive endurance which
characterise the organization of females.
4. In reference to temperature :
The degree of temperature, and the number of
deaths^ are in the inverse ratio to each other. The
greatest mortality is observed in the 1st quarter^ and
also in the winter half year^ and the least mortality in
the 8d quarter and the summer half year. The
maximum month is about April, and the minimum
about August, and the mortality passes from the latter
to the former and back again in uniform waves. The
highest temperature precedes the lowest mortality by
about a month, and an excess of it does not produce
excessive mortality from hooping-cough. The line of
temperature separating high from low mortality is 48°.
The waves of the greatest intensity of mortality occur
every second year, being then 76 and 74 cases per
week, in contrast to 47 and 52 cases per week observed
at the highest mortality in the alternate years, or
those of recession.
After a severe outbreak of the disease, there is
diminished intensity, and lessened temperature does
not then produce its ordinary ill effects. As the year
of recession leads into that of intensity, the intensity
becomes so great as to move in advance of, and not in
the rear, of the lines of temperature, contrary to the
established rule.
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«0n the Ute of V^otablo aiid Minonl Addi, ia ^ trettamit, Pirevoitlve
nd Romadial, of Cholera, ud other Bpidemic Diaordert of ^m Bowoh
8fo. LoiidoB, 1854.
Wabbbn, John C.^ M.D.
*Addraaa to the Boeton Soeietj of Natural Hiatoiy. (Two^epiea.) «vo.
Bofton, 1853.
^Remarki on lottie Peaail ImpieiaioBi In the Sa&Hitoiie Boeka of Conaeeti-
cat Bifer. 8f0. Beaton, UJ., 1854.
Wblls, T. Spbncbb.
*Praetieal Obaenratioiia on Gout and Ha Ckmij^ieatloBa, «id enHie Treat-
ment of Jointa atUfmed by Gontjr Depoaita. 8vo. London, 1854.
Wb8t, Chablbs, M.D.
*An Inqdrj into the Paihologioal impertaaee of l^aeratte of t|pe Oa
Uteri; being the Croonian Lectnrea lor the Tear 1854. 8yo« London,
1854.
*Lectores on the Diaeaiet of Infiuiey and CMlttoed. Third Bdition^ S^f
London, 1A54.
INDEX.
Adams, Wm., case of distortion of the spine, with observations on
rotation of the vertebrse as a complication of lateral curva-
ture .....
Addison, Dr., on the Keloid of Alibert and on true Keloid
Aldekson, Dr., notice of a case of skin disease, accompanied by
partial hypertrophy of the mammary gland
Aneurism, traumatic, of the ophthalmic artery
Articular affections, uric acid in blood of
connected with uretliral inflammation
Asphyxia, fatal case of, by impaction of bronchial gland in larynx
Astragalus, scrofulous caries of left
Blister serum, uric acid in ...
Blood, state of, in gout, rheumatism, and Bright's disease
changes of uric acid in, when removed from the body
in gout and rheumatism always alkaline
acid reaction of, in rheumatism, erroneous
Bronchial gland, diseased, causing fatal asphyxia
PAOK
167
27
13
221
185
209
151
1
57
49
58
219
ib.
]51
Chambers, Dr. T. K., case of moUities ossium, preceded by dege
neration of muscles . . . 19
Curling, T. B., case of traumatic aneurism of ophthalmic artery,
consequent on injury of the head, cured by ligature of the
common carotid artery . .' .221
Dods, Dr., of Bath, reference to, on rotated or contorted spine . 177
jtmriUH, QlOBsi, & cmc of btal MjAjxut Mtiscd by dctacliineiit
oradiMtNtttooDghUglud
iluaw, Dr. A. B., oa Um Uood nd cA^Arili li g<Mt,
tiBn,ii>dfidgtnffiMMfl . .
mgaak mi rtwHiriiw^ ttdr iMii illiil
iMHTMiiii. mil mi thn nihirn nf thn in ruHnil
Ooot, the biMd ind «ffiiMd fldcb b
Hmwkix, Dr. Thoiui, tam of didoctioa of ^ins
Dmi^ tedsDifale ingniiu], ndioil oun of
ijutnutmtt for aim of
t&iogjet
.am
ftf7
Xona, 0. iL, oo suukn of tlte kiiM-jomt
Joras, Dr. HAsnmu), obertaikuu of mwlRd dunga u Oe
le of tbe itomMli
Kslojiil <rf Alibert, deSnition of . > .
tnu^ deurqititm (rf
oaaesof
Dr. Die\iii^B Moonnt irf
Knee-jdnt, eicuion of .
deeotiption of operation foe exoiBioa of
7 ^and, partial bypertropb; of
treatment of
Mantell, Dr. Gideon, post-mortem examination of spine of
Mollitiea ossium, ease of, preceded bj degeneration of mnacles
urine in, analysis of
description of bone, microsoopieally examined
INDEX. 263
PAGB
Morbid effusion, uric acid in . . . . 56
MoTT, Dr. Valentine, remarks on a peculiar form of tumour of the
skin, denominated pachydermatocele . . .155
Mucous membrane of the stomach, observations on morbid changes
in , . . . . . . 87
Muscles, degeneration of, accompanying moliities ossium . . 19
Ophthahnic artery, traumatic aneurism of
Pachydermatocele, peculiar form of tumour of skin
Palpebral tumour, usually called tarsal tumour
Rheumatism, blood and effused fluids in
Rheumatic gout ....
Skin, disease of, accompanied by partial hypertrophy of mammary
gland .....
tumour of, denominated pachydermatocele
Smith, Dr. E. T., English statistics of hooping-cough
Spine, case of distortion of . . .
rotated or contorted ....
Statham, S. F., case of scrofulous caries of left astragalus
Stomach, morbid change of mucous membrane of
pyloric glands of, KoUiker's description of
nuclear masses in mucous membrane of
diffused nuclear formation in
intertubular fibroid formation in
black pigment in . . .
cystic formation in ...
mammilation of mucous membrane in
self-digestion of .
Tarsal or palpebral tumour, pathological remarks on
Uric acid, thread experiment, account of
delicacy of test for .
in certain morbid effusions
in blister serum
in blood ....
Vertebrse, rotation of, a complication of lateral curvature
post-mortem appearances in a case of
221
155
7
49
181
13
155
227
167
177
1
87
88
92
93
ib.
94
ib.
ib.
96
50
52
56
57
56
167
172
264 INDEX.
PAGE
Waltok, H. Hatkes, pathological remarks on the kind of palpebral
tomoar asuallj called tarsal tumour .7
Wells, T. Sfimcer, on the radical cure of reducible inguinal hernia
bj a new operation . . 73
Wutzer's, Professor, instrument for cure of reducible inguinal
hernia .79
KND OF VOL. XXXVir.
PRIXTKU liY J. K. ATJI^ARI), liA UnrOLOM KW CLOSi:,
VoilXXVII
Fig. la.
Figl.
U^c Aad crystallized oi fibre fixxn
BloocL Secum (veiy sSowfy cbeoL)
Uric Acid. arystaHized en fibre from BUood Senom.
Bg3.
Kg. 2.
Uric Aad crystallized on £hre ftxam BkBter Seruin.
Ef flc5resctaice cf Phosphates on flae surfeuse c£ ihc
dried Scrvim partly ccncealing ihs Uric Acid can Sbre.
^ Kror&Xjni.
Ead&VSist ]n^ :&«k& Guden.
264 INDEX.
PAOE
Walton, H. Hatnes, pathological remarks on the kind of palpebral
tumoor usually called tarsal tumour .7
Wells, T. Spencer, on the radical cure of reducible inguinal hernia
by a new operation . . 73
Wutzer's, Professor, instrument for cure of reducible inguinal
hernia .79
KND OF Vol. XXWIf.
PRINTED BY J. K. ADLARI), BA;lTIU)L(>Mi:W CLOSE.
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